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PERCUSSION  OUTLINES. 


BY 


E.  G.  CUTLER,  M.  D. 


ASSISTANT  IS  PATHOLOGICAL  ANATOMY,  HARVARD   MEDICAL   SCHOOL  j    VISITING   PHTSICIAN 

TO  THE  CARNEY  HOSPITAL;    PHYSICIAN   TO   OUT-PATIENTS,   MASSACHUSETTS 

GENERAL  HOSPITAL;   PATHOLOGIST  TO  THE   CITY   HOSPITAL, 


G.  M.  GARLAXD,  M.  D. 

ASSISTANT  IN    CLINICAL   MEDICINE,   HARVARD   MEDICAL   SCHOOL;   PROFESSOR  OF  THORACIC! 

DISEASES,   UNIVERSITY   OF   VERMONT  ;    VISITING   PHYSICIAN  TO  THE   CARNEY 

HOSPITAL;  PHYSICIAN  TO  THE  BOSTON  DISPENSARY. 


BOSTON: 
HOUGHTON,  MIFFLIN  AND  COMPANY, 

11   BAST  si:yknti;i:\tii   BTBKBT,   m:w    voiuC 

CIjc  lUbcrs'tttc  g)rtM,  Cimbrrtrcjr. 

1882. 


Copyright,  1882, 
By  E.  G.  CUTLER  and  G.  M.  GARLAND 


The  Riverside  Press,  Cambridge : 
Stereotyped  and  Printed  by  II.  0.  Houghton  &  Co 


PKEFACE. 


This  book  is  intended  to  teach  students  the  ana- 
tomical position  of  the  thoracic  and  abdominal  viscera 
in  the  living  subject,  and  to  portray  such  boundaries  of 
those  organs  as  are  accessible  to  percussion.  The  al- 
most daily  necessity  in  every  physician's  practice  for  de- 
termining the  position  and  size  of  some  concealed  organ 
will,  we  trust,  prepare  a  cordial  welcome  for  our  book 
from  those  who  prefer  well-defined  knowledge  to  un- 
certain guess-work.  We  have  devoted  our  attention 
mainly  to  the  normal  condition,  and  what  we  say  re- 
garding pathological  phenomena  is  intended  rather  as  a 
guide  to  the  proper  methods  for  detecting  abnormal 
deviations  than  as  a  full  description  of  the  same.  With 
regard  to  the  preparation  of  the  book  we  will  add  that 
it  is  essentially  a  condensed  abstract  of  the  German  lit- 
erature upon  this  subject,  as  contributed  by  Weil,  Fer- 
ber,  Luschka,  and  Gerhardt.  We  have,  however,  re- 
peatedly and  carefully  reviewed,  in  our  own  practice  and 
at  the  autopsy  table,  the  points  which  we  present,  and 
have  convinced  ourselves  that  they  are  correct. 


CONTENTS. 


MM 

CHAPTER  L 
Method  in  Pebcussion 1 

CHAPTER  n. 
The  Sxebndm,  Diaphragm,  and  Pleuba 8 

CHAPTER  HI. 
Thb  Lungs 14 

CHAPTER  IV. 
The  Heabt  and  the  Pebicabdidm 30 

CHAPTER  V. 
The  Liveb 41 

CHAPTER  VI. 
The  Spleen 46 

CHAPTER  VH. 
The  Stomach 54 

CHAPTER  VHL 
The  Kidneys 58 

CHAPTER  LX. 
The  Bladdeb .'       .    60 

CHAPTER  X. 
The  Utbbus 62 

CHAPTER  XL 
The  Pebitonbum 04 


PERCUSSION    OUTLINES. 


CHAPTER  I. 

METHOD  IN  PERCUSSION. 

TriE  first  essential  to  intelligent  percussion  is  a  cor- 
rect method.  Much  has  been  written  about  pleximeters 
of  varied  form  and  size  —  about  hammers  of  different 
weight  and  material,  but  the  secret  of  successful  per- 
cussion lies  in  little  details  of  method  rather  than  in 
the  fibre  of  any  instrument.  According  to  our  own 
opinion  the  best  pleximeter  and  hammer  are  the  human 
finger.  It  is  always  available.  It  is  never  forgotten  or 
lost.  As  a  pleximeter  it  furnishes  a  wide  scope  in  size, 
from  its  tip  to  its  entire  palmar  surface,  and  it  need 
never  frighten  the  most  timid  child.  It  affords  the  best 
and  most  instantaneous  information  regarding  the  re- 
sistance of  the  parts  percussed.  The  skillful  use  of  the 
fingers  is  somewhat  more  difficult  to  acquire  than  that 
of  a  pleximeter  and  hammer,  but  any  one  who  can  per- 
cuss well  with  the  fingers  can  also  do  well  with  instru- 
ments, although  the  reverse  of  this  proposition  is  by  no 
means  true. 

It  is  a  matter  of  choice  whether  one  or  more  fingers 
be  used  on  each  hand.  We  always  employ  the  last 
phalanx  of  the  middle  finger  of  the  left  hand  as  the 
pleximeter,  while  the  other  fingers  are  raised  from  the 
chest,  so  as  not  to  interfere  with  the  sound  vibrations. 
l 


2  PERCUSSION  OUTLINES. 

The  rounded  end  of  the  middle  finger  of  the  right  hand 
forms  our  hammer,  and  we  strike  the  pleximeter  just 
behind  the  nail  in  such  a  manner  that  the  hammer  nail 
shall  not  touch  the  skin  of  the  underlying  finger  —  that 
is,  we  strike  with  that  fleshy  part  of  the  finger  where  the 
distal  surface  curves  into  the  palmar. 

The  pleximeter  should  be  applied  firmly  with  sufficient 
pressure  to  prevent  the  slipping  about  of  the  soft  parts 
when  the  blow  is  given  ;  and  this  pressure  should  be 
uniform  for  the  two  sides  of  the  chest.  What  is  of 
still  more  importance,  the  percussion  blows  should  be 
given  with  uniform  force,  especially  when  comparing  op- 
posite sides  of  the  chest.  We  have  seen  students  un- 
able to  demonstrate  the  most  striking  differences  of 
percussion  tones  simply  because  they  delivered  their 
blows  with  constantly  varying  force.  The  relative  mer- 
its of  light  and  heavy  percussion  will  be  discussed  later, 
but  whether  light  or  heavy,  the  blows  must  be  uni- 
form. 

Again,  in  comparing  two  sides  of  a  chest,  one  should 
always  percuss  symmetrical  spots.  If  the  pleximeter 
finger  be  laid  upon  a  rib  on  the  one  side,  it  should  not  be 
transposed  to  an  intercostal  space  On  the  other,  but 
should  be  placed  on  the  symmetrical  point  of  the  com- 
panion rib. 

Taking  into  careful  account  the  correct  use  of  the 
hands,  attention  should  next  be  turned  to  the  position 
of  the  patient.  If  the  subject  of  percussion  be  a  man, 
he  should  be  exposed  to  the  skin,  due  regard  being  paid 
to  the  temperature  of  the  room.  Our  rule  is  as  fol- 
lows :  We  tell  a  patient  to  strip  to  the  waist  and  then 
to  put  on  his  coat.  This  leaves  the  front  of  the  body 
bare  and  easily  accessible.  When  we  reach  the  axillary 
region  one  arm  can  be  slipped  out  of  its  sleeve,  and 
while  the  back  is  examined  the  coat  can  be  put  on  in  the 


METHOD  IN  PERCUSSION.  3 

reversed  position.  A  similar  amount  of  exposure  is  not 
usually  advisable  with  women,  but  the  judicious  combi- 
nation of  a  thin  undershirt  and  a  shawl,  or  an  unstarched 
dressing-sack  alone,  will  allow  ample  scope  for  a  skillful 
percussor.  The  patient  should  be  told  to  sit  quietly  and 
naturally,  with  the  chest  muscles  relaxed.  Most  men, 
when  stripped  and  approached  for  percussion,  will  throw 
back  their  shoulders  and  protrude  their  chest  as  if  on 
dress  parade.  The  muscular  tension  thus  produced  will 
always  modify  the  sounds  from  the  organs  beneath. 
The  two  sides  of  the  body  should  be  held  symmetrically, 
and  the  face  should  be  directed  straight  forward,  in  order 
that  the  sounds  of  the  apices  may  not  be  obscured  by 
tension  of  the  overlying  muscles.  It  is  immaterial 
whether  the  hands  hang  at  the  side  or  are  placed  on 
top  of  the  head.  Hanging  at  the  side,  the  arms  are 
out  of  the  way,  except  during  percussion  of  the  axillary 
regions.  A  slight  withdrawal  of  the  arm  backward,  how- 
ever, will  give  access  to  the  anterior  part  of  the  axillary 
region,  while  a  similar  slight  advance  of  the  arm  will 
expose  the  posterior  part  of  the  same  space.  If  one 
hand  is  placed  upon  the  head,  which  is  on  some  accounts 
the  raosl  convenient  position  during  pei'cussion  of  the 
lower  border  of  the  lung,  it  should  be  remembered  that 
such  elevation  of  the  arm  carries  the  skin  and  ribs  a 
trifle  upward,  and  an  allowance  must  be  made  fortius 
deflection  in  the  subsequent  record  of  the  border  ob- 
tained. 

Patients  should  not  stand  during  percussion.  They 
should  be  allowed  to  sit  on  ;i  stool  or  on  a  chair  without 
arms.  If  they  are  too  weak  to  sit  up  and  we  are  obliged 
to  pei'CU88  them  in  bed,  we  should  be  careful  to  note  that 
the  body  is  straight,  and  that  the  shoulders  are  squarely 
placed  and  not  twisted  out  >A'  symmetry  by  underlying 
bolsters   or  pillows.     Reference  should  also  be  made  to 


4  PERCUSSION   OUTLINES. 

the  fact  that  the  position  of  the  internal  organs  varies  with 
changes  in  the  position  of  the  body,  a  point  which  will 
be  treated  of  later  under  the  head  of  the  passive  mo- 
bility of  the  percussion  boundaries. 

Examination  of  the  abdomen  is  best  made  with  the 
subject  lying  upon  the  back,  with  the  head  slightly  raised 
and  the  knees  drawn  up,  so  as  to  relax  the  abdominal 
wall.  To  expose  the  spleen,  the  subject  should  lie  upon 
the  right  side,  or  half  way  between  the  right  lateral  and 
the  prone  position. 

Having  thus  discussed  the  preliminary  stages  of  our 
task,  we  will  now  describe  the  manner  in  which  an  inter- 
nal organ  may  be  outlined.  It  will  be  learned  later  that 
only  a  small  portion  of  all  the  anatomical  borders  are 
accessible  to  percussion.  Piorry,  in  the  enthusiasm  of  a 
new  study,  claimed  that  every  organ  of  the  body  emits  a 
sound  peculiar  to,  and  distinctive  of,  itself.  If  this  were 
true,  all  the  internal  organs  might  be  mapped  out  with  an- 
atomical nicety.  Skoda  was  the  first  to  vigorously  attack 
this  idea.  He  maintained  that  aerated  organs  are  resonant 
by  reason  of  the  contained  air.  Those  organs  which  con- 
tain no  air  are  simply  non-resonant,  and  the  sounds  which 
they  emit  when  struck  are  indistinguishable  from  each 
other.  The  question  of  percussion  outlines  resolves  itself 
into  the  tracing  of  boundaries  between  organs  which  are 
very  resonant,  and  those  which  are  less  resonant  or  pos- 
sessed of  a  different  quality  of  resonance,  and  those  which 
are  non-resonant.  Thus  it  is  easy  to  trace  the  boundary 
between  the  lung  and  the  liver  where  they  lie  in  appo- 
sition, but  impossible  to  distinguish  the  line  of  contact 
between  the  heart  and  the  liver. 

In  order  to  define  any  border  which  comes  within  the 
province  of  our  search  we  should  percuss  toward  that 
border  from  either  side  —  and  alternately  from  both  sides 
—  in  lines  which  are  perpendicular  to  its  known  anatom- 


METHOD  IN   PERCUSSION.  5 

ical  course.  Inasmuch  as  most  of  the  percussion  boun- 
daries run  transversely  across  the  body,  we  have  adopted 
the  following  series  of  perpendicular  lines,  which  should 
be  followed  methodically  and  in  succession:  — 

•Sternal  line  ....     Along  the  border  of  the  sternum. 

Parasternal  line  .  .  Half  way  between  the  sternal  and 
mammillary  lines. 

Mammillary  line  .  .  Through  the  nipple  on  the  male.  On 
the  female  this  line  should  be  drawn 
perpendicularly  downward  from  about 
the  middle  of  the  clavicle. 

Anterior  axillary  line     Along  the  anterior  border  of  axilla. 

Axillary  line  .  .  .  From  the  summit  of  the  axilla  down- 
wan  Is. 

Posterior  axillary  line    Along  posterior  border  of  axilla. 

Scapula  line  .  .  .  Through  the  apex  of  the  scapula  when 
the  arms  are  banging  at  the  sides. 

Vertebral  line  .  .  .  Between  the  scapular  and  vertebral 
column. 

To  illustrate  the  use  of  these  lines,  let  us  suppose  that 
tin'  lower  border  <>f  the  right  lung  is  the  object  of  inves- 
tigation. In  such  case  one  should  begin  on  the  sternal 
line,  and  percuss  downward  until  a  point  is  reached 
where  the  resonance  of  the  lung  ceases,  and  the  flatness  of 

the  liver  begins.     Having  repeated  the  percussion  often 

enough  to  be  sure  of  such  change,  this  point  should  be 
designated   by   a    pencil    mark  on   the  skin.       Then   the 

same   steps   should    be    repeated     along     the     parasternal, 

mammillary,  and  anterior  axillary  lines,  and  so  on  to  the 

vertebral     line,    the    point    of     change   of    sound    in    each 

case  being  marked.     Then  if  these  points  I onnected 

by  a    continuous  line,  one  will  have  a  sketch  of  the  lower 

border  of  the  lung.     It   is  always  serviceable  to  percuss 

toward  the  bord.-r  sought,  uol  only  from  above  down- 
ward,   but    also    from    below    upward,    in    which    cafl ie 


6  PERCUSSION  OUTLINES. 

would  mark  the  points  where  flatness  changes  to  reso- 
nance. 

In  outlining  the  heart  one  should  percuss  in  the 
sternal,  parasternal,  and  mammillary  lines,  and  even  in 
the  anterior  axillary  and  axillary  lines.  Under  normal 
conditions,  the  left  border  of  the  heart,  as  shown  in 
Plate  IV.,  curves  downward  and  runs  parallel  with  the 
mammillary  line,  hence,  to  define  this  border,  it  will  be 
necessary  to  approach  it  in  oblique  lines  from  the  left 
shoulder  and  left  axillary  region. 

It  is  difficult  to  find  a  good  pencil  for  marking  the  skin. 
Ink  spreads  and  dries  slowly.  Burnt  cork  is  very  good, 
but  inconvenient  to  carry,  and  an  ordinary  lead  pencil  is 
too  hard  to  make  a  mark  on  soft  skin.  Chalk  and  car- 
bon work  well  for  a  time,  but  they  rapidly  absorb  oil 
from  the  skin,  and  cease  to  mark  unless  refreshed  with 
sand  paper.  We  have  found  a  very  convenient  marker 
in  the  pencils  which  actresses  use  for  staining  their  eye- 
lids. These  pencils  are  made,  like  ordinary  cosmetics, 
from  grease  stained  with  lamp-black  or  vermilion.  They 
are  put  up  in  little  tin  cases,  with  slides  for  pushing  them 
in  and  out,  and  can  be  carried  about  in  the  pocket. 
They  can  be  obtained  at  any  perfumery  store. 

We  must  again  emphasize  the  necessity  of  percussing 
in  straight  lines,  and  of  carefully  completing  one  line 
before  beginning  another.  Students  are  very  apt  to 
percuss  across  the  chest  in  a  zigzag  direction  or  wander 
about  in  circles.  Such  percussion  teaches  nothing,  and 
only  serves  to  confuse  the  examiner. 

A  word  in  regard  to  the  relative  merits  of  light  and 
heavy  percussion.  Undoubtedly  heavy  percussion  has 
its  place  and  serves  a  good  purpose,  especially  over  thick 
muscles  on  the  back,  and  in  bringing  out  the  dullness 
of  deep-seated  consolidation.  In  outline  percussion, 
however,  on  the  lateral  and  anterior  aspects  of  the  body, 


METHOD  IX  PERCUSSION.  7 

light  percussion  alone  should  be  employed.  In  crossing 
the  boundary  between  a  resonant  and  a  non-resonant 
organ,  if  our  blows  are  heavy,  the  resonance  of  the 
former  organ  will  be  so  transmitted  over  the  latter  that 
the  line  of  demarkation  will  apparently  lie  several  cen- 
timeters away  from  its  actual  position.  We  have  found 
that  the  best  results  are  obtained  with  extremely  light 
percussion.  The  blow  should  never  be  given  from  the 
elbow,  but  from  the  wrist  or  from  the  metacarpal  joint 
of  the  hammer  finger.  Where  the  chest  is  at  all  tender, 
and  especially  in  percussing  children,  we  always  keep  the 
hand  quiet,  and  deliver  our  blows  with  the  finger  alone. 

The  burden  of  this  book  is  the  normal  percussion 
outlines  of  the  body,  and  we  devote  but  relatively  small 
space  to  pathological  deviations.  In  presenting  the  sub- 
ject thus,  we  have  been  actuated  by  the  conviction  that 
perfect  familiarity  with  the  normal  is  the  only  true  guide 
to  the  abnormal.  One  who  has  a  systematic  method  of 
Bearching  for  the  normal,  and  pursues  that  method  rigor- 
ously in  every  case,  will,  never  fail  to  detect  abnormal 
deviations. 


CHAPTER  II. 

STERNUM. 

The  sternum  consists  of  the  manubrium,  corpus  sterni, 
and  the  ensiform  cartilage.  It  ordinarily  lies  in  the  me- 
dian line,  opposite  the  vertebral  column.  Congenital 
and  acquired  deformities  of  either  side  of  the  chest  will 
of  course  alter  its  position.  With  pleuritic  effusions  the 
sternum  swings  toward  the  affected  side  like  a  pendulum, 
the  lower  end  traveling  four  to  five  centimeters,  while 
the  upper  end  moves  only  two  centimeters. 

The  manubrium  is  normally  quite  resonant  —  the 
sound  is  neither  tympanitic  nor  vesicular,  but  has  a  qual- 
ity of  its  own.  It  may  be  rendered  dull  by  an  over- 
filling of  the  veins  from  valvular  disease  of  the  heart ; 
by  aneurism  of  the  arch  of  the  aorta ;  by  pericardial 
effusion,  and  by  pus  gravitating  from  abscesses  in  the 
neck.  In  the  last-named  case  it  is  important  to  notice 
that  the  dullness  does  not  extend  below  the  manubrium, 
because  the  firm  adhesion  of  the  membranes  of  the  ante- 
rior mediastinum  deflect  the  gravitating  pus  into  the  pos- 
terior mediastinal  space. 

The  resonance  of  the  sternum  is  clearest  and  loudest  be- 
tween the  second  and  fourth  ribs.  It  is  also  clear  between 
the  fourth  and  sixth  ribs,  although  it  here  crosses 
the  heart,  and  is  to  a  great  extent  in  direct  contact 
with  that  organ.  It  would  seem  that  the  sternum  is  an 
excellent  conductor  of  sound  from  the  neighboring  lungs, 
and  thus  conceals  the  flatness  of  the  underlying  heart. 


ANATOMY. 


DIAPHRAGM. 


Anatomy. 

Viewed  from  above,  the  diaphragm  presents  a  dome- 
like projection  into  each  side  of  the  thorax,  with  a  nearly 
horizontal  plane  connecting  the  summits  of  the  domes. 
The  upper  surface  is  somewhat  elliptical  in  shape,  the 
transverse  diameter  being  the  longest.  The  diaphragm 
consists  of  two  parts,  a  tendinous  portion  —  pars  phre- 
nica  —  which  forms  the  plane  above,  and  a  muscular 
portion — pars  costal  is  —  which  constitutes  the  sides  of 
the  domes.  The  muscular  portion  has  a  long  line  of 
attachment  extending  from  the  sternum  along  the  bor 
der  of  the  ribs  to  the  vertebral  column.  The  sternal 
segment  rises  chiefly  from  the  apex  of  the  ensiform  car- 
tilage, and  is  immediately  lost  in  the  tendinous  layer. 
The  costal  segment  begins  with  one  serration  from  the 
seventh  costal  cartilage,  and  another  from  the  outer  por- 
tion of  the  eighth  cartilage.  On  the  ninth  rib  the  ser- 
rations extend  about  a  finger-breadth  beyond  the  carti- 
Iage,  on  to  the  costal  bone.  From  here  to  the  twelfth  rib, 
the  muscle  is  attached  to  the  osseous  parts  and  the  inter- 
costal spaces.  Its  serrations  also  interdigitate  with  the 
corresponding  projections  of  the  transverse  abdominal 
muscle.  The  vertebra]  segment  takes  its  origin  from  the 
firsl  tour  lumbar  vertebras. 

Starting  from  this  long  line  of  attachment,  the  pars 
COStalis  rises  directly  upward,  and  lies  in  contact  with  the 
chest  wall  for  a  distance  which  varies  on  different  sides 
of  tin- chest  and  with  different  phases  of  respiration.  On 
reaching  the  lower  border  of  the  lung  and  the  heart,  it  is 
reflected  beneath  those  organs  and  becomes  the  pars 
phrenica. 

The   summit    of    the    diaphragm    changes  with   every 


10  PERCUSSION  OUTLINES. 

stage  of  respiration,  but  at  the  end  of  ordinary  expiration 
it  coincides  on  the  right  side  with  a  horizontal  line  drawn 
through  the  sternal  ends  #f  the  fifth  pair  of  ribs,  and  it  is 
a  costal  space  lower  on  the  left  side.  On  the  back  it  cor- 
responds to  the  ninth  dorsal  vertebra. 

Percussion  of  the  Diaphragm. 

The  position  of  the  diaphragm  cannot  be  defined  by- 
means  of  any  sound  or  modification  of  resonance  peculiar 
to  itself.  It  is  only  by  comparing  its  anatomical  rela- 
tions to  other  organs  with  the  percussion  boundaries  of 
those  organs  that  we  are  able  to  form  any  opinion  con- 
cerning it. 

The  most  important  points  to  determine,  are :  — 

1.  The  line  of  transition  from  the  pars  costalis  to 
the  pars  phrenica.  This  corresponds  to  the  lower  border 
of  the  lung,  and  may  therefore  be  deferred  to  the  discus- 
sion of  that  border. 

2.  The  position  of  the  dome.  Gerhardt  says  it  is  idle 
to  try  to  define  the  arch  of  the  dome,  owing  to  its  dis- 
tance from  the  chest  wall.  Weil  and  Ferber  think  it 
can  be  defined  by  strong  percussion,  but  this  is  a  difficult 
task,  and  usually  we  can  determine  the  probable  height 
of  the  diaphragm  only  by  inference  from  the  position  of 
other  organs.  When  the  dome  of  the  diaphragm  is  de 
pressed  into  the  abdomen  by  a  large  pleuritic  effusion,  it 
becomes  readily  accessible  to  percussion,  and  may  often 
be  felt. 

PLEUEA. 

Anatomy. 

The  pleural  membranes  are  divided  into  four  parts,  ac- 
cording to  the  organs  with  which  they  are  associated. 
These  parts  are  :  — 


ANATOMY.  11 

Pars  pulmonis,  which  directly  envelops  the  lung  and 
cannot  be  detached  from  the  Bame. 

Pars  phreniea,  which  covers  the  diaphragm. 

1'uj-x  mediastinalis,  which  helps  form  the  partition  be- 
tween the  two  halves  of  the  chest. 

Pars  costalis,  which  lines  the  inner  surface  of  the  ribs, 
intercostal  spaces,  and  a  portion  of  the  sternum. 

At  the  apex  of  the  chest,  behind  the  sternum  and 
along  the  vertebral  column,  the  pars  costalis  is  reflected 
inward,  to  form  the  pars  mediastinals,  and  these  lines  of 
reflection  constitute  respectively  the  Buperior,  anterior, 
and  posterior  borders  of  the  pleural  cavity.  The  inferior 
border  of  that  cavity  is  formed  by  the  reflection  of  the 
costal  into  the  diaphragmatic  layer,  or  pars  phrenica. 
The  most  important  of  these  borders,  for  percussion,  are 
the  superior,  anterior,  and  inferior. 

The  si(/>cri'>r  ln,r<l<  rs  coincide  accurately  with  the  su- 
perior binders  of  the  lungs,  and  therefore  require  no  sep- 
arate notice  at  this  point.  See  description  of  lungs, 
page  14. 

The  anterior  borders  start  on  either  side  at  the  articu- 
lation of  the  clavicles  with  tie-  sternum,  Plate;  I.,  a  b,  c  d. 
They  advance  obliquely  downward  and  inward,  behind 
the  manubrium,  until  they  reach  the  level  of  the  inner 
extremities  of  the  second  ribs,  where  they  come  into  con- 
tact  with  each  other.  Thence  they  proceed  together 
downward  a  little  to  tin'  left  of  the  median  line,  as  far 
as  the  fourth  pair  of  ribs*  when  they  separate.  The 
right  border  continues  still  downward,  with  a  slight  in- 
clination to  the  right,  until  it  meet-,  the  inferior  bonier  of 
the  right  pleura,  in  the  median  line  of  the  sternum,  at  the 
Level  of  the  sixth  intercostal  space. 

The  left  anterior  border  bends  Bomewhal  sharply  to 
the  left  at  the  fourth  rib,  and  crosses  the  cardiac  area  in 

an    irregularly   diagonal    direction    until    it    reaches    the 


12  PERCUSSION   OUTLINES. 

parasternal  line  in  the  sixth  intercostal  space.  Here  it 
sweeps  in  an  easy  curve  across  the  seventh  costal  cartil- 
age, and  is  lost  in  the  inferior  border  of  the  left  pleura. 

The  inferior  borders  of  the  pleurae  convex  downward 
on  either  side.  The  left  one  runs  obliquely  downward 
and  outward  from  the  outer  third  of  the  sixth  or  sev- 
enth costal  cartilage  to  the  bony  portion  of  the  twelfth 
rib  behind.  Its  termination  is  about  on  a  level  with  a 
horizontal  line  which  halves  the  twelfth  pair  of  ribs. 
In  its  course  it  crosses  the  bony  end  of  the  eighth  rib 
in  the  mammillary  line,  and  from  there  on  it  comes  in 
contact  only  with  the  bony  portion  of  the  ribs.  It 
reaches  the  tenth  rib  in  the  axillary  line.  The  lowest 
point  of  the  pleural  cavity  is  sometimes  close  to  the 
vertebral  column  and  sometimes  a  little  out  from  the 
same.  It  maybe  as  far  out  as  the  scapular  line  in  some 
cases. 

The  right  inferior  border  runs  from  the  median  line 
of  the  sternum  outward  and  downward  along  the  sixth 
costal  cartilage  or  the  sixth  intercostal  space  to  the  outer 
third  of  the  seventh  costal  cartilage,  whence  it  proceeds 
in  nearly  the  same  manner  as  on  the  left  side.  It  is 
noticeable,  however,  that  the  pleural  border  on  the 
left  side  is  a  trifle  lower  than  that  on  the  right  side, 
which  harmonizes  with  the  fact  that  the  left  lung  is 
longer  though  smaller  than  the  right  one. 

The  posterior  borders  of  the  pleura?  form  perpendicu- 
lar lines  on  either  side  of  the.  vertebral  column. 

Notice  :  1.  The  inferior  border  of  the  pleura  does 
not  reach  so  low  as  the  line  of  attachment  of  the  dia- 
phragm, which  runs  along  the  costal  arch  from  the  ensi- 
form  cartilage  to  the  outer  extremity  of  the  twelfth  rib. 
The  diaphragm  in  this  region  is  intimately  attached  to 
the  ribs  and  intercostal  spaces. 

2.  A  portion  of  the  pericardium  has  no  pleural  cover- 


ANATOMY.  13 

ing,  owing  to  the  oblique  course  of  the  anterior  border  of 
the  left  pleura.  This  exposed  region  has  a  triangular 
shape  with  its  apex  upward,  and  within  this  triangle  the 
pericardium  lies  in  direct  contact  with  the  chest  wall. 
The  portion  of  the  pleura  (pleura  pericardiaca)  which 
does  overlie  the  pericardium  is  intimately  attached  to  the 
latter. 

3.  The  anterior  borders  of  the  pleurae  touch  each  other 
only  between  the  second  and  fourth  pair  of  ribs,  and  it 
is  here  only  that  the  posterior  surface  of  the  sternum  is 
wholly  covered  by  pleura. 

4.  A  triangular  space  behind  the  upper  part  of  the 
manubrium  is  free  from  pleural  covering.  Certain  im- 
portant organs  lie  behind  this  space.  A  needle  thrust 
through  the  manubrium  at  the  angle  formed  by  the 
pleural  layers  would  pierce  the  upper  part  of  the  peri- 
cardium, which  rises  as  high  as  the  first  pair  of  ribs. 
Above  the  pericardium  one  would  wound  first  the  vena 
innominata,  and,  back  of  that,  the  aorta.  In  childhood 
this  space  also  contains  the  large  thymus  gland. 


CHAPTER  III. 

LUNGS. 

Anatomy. —  The  lungs  present  three  surfaces  and  five 
borders  for  consideration.  The  external  or  costal  sur- 
face is  convex  outward,  corresponding  to  the  concavity 
of  the  chest  Avail,  and  it  is  a  sort  of  spherical  triangle 
with  its  apex  above,  and  the  lower  pulmonary  border  for 
the  base.  The  inferior  surface  is  also  a  spherical  triangle 
with  its  concavity  looking  down  upon  the  diaphragm. 
The  median  or  mediastinal  surface  looks  toward  the  cen- 
tre of  the  body,  and  is  pierced  by  the  trachea  and  blood- 
vessels which  administer  to  the  functions  of  the  lungs. 

Pulmonary  Borders. — The  superior  border  passes  yoke- 
like over  the  shoulder  at  three  to  five  centimeters  (two 
to  three  finger-breadths)  above  the  clavicle.  Plate  IV., 
G,  H.  Anteriorly,  it  runs  close  to,  and  parallel  with,  the 
posterior  border  of  the  sterno-cleido-mastoid  muscle,  until 
it  reaches  the  sterno-clavicular  articulation,  when  it  be- 
comes the  anterior  border.  On  the  back  it  is  slightly 
concave  upward,  and  terminates  at  the  level  of  the  spi- 
nous process  of  the  seventh  cervical  vertebra.  Plate 
VII.,  A  B. 

The  anterior  border  of  the  right  lung  corresponds  accu- 
rately to  the  anterior  border  of  the  right  pleura,  as  given 
on  page  11,  Plate  I. 

The  anterior  border  of  the  left  lung  runs  also  parallel 
with  its  pleura,  as  far  as  the  inner  extremity  of  the  fourth 
rib.     Here  it  bends  sharply  to  the  left,  and  lies  along  the 


LUNGS. 


15 


fourth  costal  cartilage  as  far  as  the  parasternal  line.  Then 
descending  slightly  across  the  fourth  "intercostal  space,  it 
turns  again  toward  the  median  line  in  a  half-moon  curve — 
Incisura  cardiaca  —  and  approaches  the  sternum  until  it 
reaches  the  sixth  costal  cartilage,  when  it  again  bends  to  the 
left  and  is  lost  in  the  inferior  border.  This  peculiar  deflec- 
tion of  the  border  produces  a  tongue-like  projection  — 
lingala  pulmonis  —  which  overlies  the  apex  of  the  heart. 
The  inferior  border  of  the  left  lung  is,  in  front,  a 
little  lower  than  that  of  the  right  lung.  This  difference 
amounts  to  one  and  a  half  centimeters  between  the  mam- 
millary  and  parasternal  lines,  but  no  perceptible  differ- 
ence exists  on  the  back.  The  following  table  shows  the 
relative  positions  of  the  inferior  border  on  the  two 
sides. 


1  rual     aud    mammillary 

lines 
Axillary  line      . 
Bcapular  line     . 
Vertebral  line  .... 


Upper  border  of  6  c  li 
rib. 
<  tosses  7th  rib. 

tea  loth  rib. 
•s  1  ltll  lib. 


Lower     border 

6th  rib. 
( Irosses  7th  rib. 
<  ru-sis  loth  rib. 
( Irosses  1 1th  rib. 


of 


This  tabic  represents  the  position  of  the  borders  at  the 
end  of  normal  expiration.  The  respiratory  modifications 
of  the  same  will  be  noted  later. 

Tin:  posterior  borders  run  parallel  with  the  vertebral 
column.  Little  or  no  information  can  be  obtained  re- 
garding them  by  percussion,  except  in  cases  of  pleurisy, 
when  we  find  them  shortened  by  the  general  contraction 
of  the  lull 

The  antero-posterior  borders,  which  bound  the  lower 

part   of    the  mediastinal   surfaces,  are   inaccessible  to  per- 
cussion. 

Incisurce  Interlvbtibircx.  —  Each  lung  is  divided  into 
lobes  by  incisune,  which  extend  from  the  surface  to  the 
root    of    the   lung,  and  are    lined    by   reflections  of    the 


16  PERCUSSION   OUTLINES. 

visceral  pleura.  The  right  lung  has  three  lobes,  the  left 
lung  two. 

The  main  incisura  begins  on  either  side,  behind,  at  the 
level  of  the  spinous  process  of  the  third  dorsal  vertebra. 
This  also  coincides  with  the  spines  of  the  scapulae,  when 
the  arms  hang  at  the  sides. 

On  the  left  side,  the  incisura  runs  obliquely  downward 
and  forward,  so  as  to  cross  the  fourth  rib  in  the  axillary 
line,  and  ends  in  the  lower  border  of  the  lung  on  the  sixth 
rib  in  the  mam  miliary  line.     Plate  II.,  E  D. 

On  the  right  side  the  incisura  divides  into  two 
branches,  about  five  to  six  centimeters  above  the  apex 
of  the  scapula.  The  upper  branch  runs  forward,  with 
very  slight  descent,  and  ends  in  the  anterior  border  of 
the  right  lung  at  the  fourth  or  fifth  costal  cartilage.  In 
the  mammillary  line  it  stands  at  the  level  of  the  third 
rib. 

The  lower  branch  runs  obliquely  downward  and  for- 
ward until  it  reaches  the  inferior  border  of  the  lung  at  the 
sixth  costal  cartilage  near  the  mammillary  line.  These 
incisure  cannot  be  defined  by  percussion,  except  in  cases 
of  lobar  infiltration  of  pneumonia. 

Notice  :  1.  In  the  position  of  ordinary  expiration,  the 
lower  border  of  the  lung  on  either  side  does  not  reach  to 
the  bottom  of  the  pleural  cavity,  but  is  elevated  above  the 
same  by  a  distance  varying  on  different  sides  of  the 
chest.  Plate  II.  During  inspiration  the  lung  descends 
until,  with  the  fullest  breath,  it  occupies  the  entire  cavity. 
With  the  following  expiration,  the  lower  border  glides 
upward  to  resume  its  former  position.  The  space  which 
is  thus  alternately  occupied  and  abandoned  by  the  lung 
is  called  the  complemented  space  (Gerhaudt),  or  the 
sinus  phrenico-costalis  (Weil).  As  the  lung  deserts  this 
space,  the  diaphragmatic  and  costal  layers  of  the  pleura 
are  brought  into  contact,  and  thus  the  space  becomes 
temporarily  obliterated. 


LUNGS. 


17 


The  variations  in  the  depth  of  this  space  on  different 
sides  of  the  chest  are  shown  in  the  following  table 
(Weil)  :  — 


Parasternal  line 
Mammillary  line 
Axillary  line 
Scapular  line 

Vertebral  line    . 


RIGHT 

SIDE. 

LEFT    SIDE. 

2+  ctm. 

3  ctm. 

6 

" 

6      " 

10 

" 

10       " 

4  to  5 

« 

4  to  5       " 

4  to  5 

" 

4  to  5      " 

These  figures  represent  the  condition  of  ordinary  expi- 
ration. With  forced  expiration  they  may  be  much  in- 
creased. 

2.  The  anterior  border  of  the  left  lung,  in  the  cardiac 
region,  does  not  occupy  the  whole  of  the  space  allotted  to 
it.  Plate  L,  Q.  This  excess  of  room,  reserved  for  the 
play  of  the  pulmonary  border,  is  called  the  sinus  me- 
diastino-costalis,  and  it  will  be  seen  later  that  the  recog- 
nition of  its  condition  is  very  important,  especially  for 
the  diagnosis  of  emphysema.  The  widest  portion  of  this 
sinus  is  in  the  fourth  intercostal  space,  where  it  is  over 
three  centimeters. 

3.  The  apex  of  the  heart  does  not  touch  the  chest  wall, 
but  is  separated  from  the  same  by  the  lingula  pulmonis. 

4.  The  lowest  point  of  the  lung  is  in  the  scapular  line. 

PERCUSSION   OF  THE   LUNGS. 

The  only  boundaries  of  the  lungs  which  can  be  defined 
bv  percussion  are  the  Buperioi  and  inferior  borders,  and 
so  much  of  the  left  anterior  border  as  lies  across  the 
cardiac  area. 

Superior  Borders.  —  The  apex  of  the  lung  rises  above 
the  clavicle  from  three  to  five  centimeters.  The  su- 
perior bonier  extends  from  the  inner  end  of  the  clavi- 
cle, at  first  upward  along  the  posterior  edge  of  the 
sterno-cleido-mastoid  muscle,  and  then  over  the  shoulder 
2 


18  PERCUSSION   OUTLINES. 

in  a  gentle  sweep,  to  the  spinous  process  of  the  seventh 
cervical  vertebra.  Plate  VII.,  A  B.  On  the  back,  these 
borders  concave  upward. 

The  distinction  between  the  pulmonic  resonance  of 
the  apex  and  the  tympanitic  resonance  of  the  trachea 
in  front  can  best  be  made  out  by  light  percussion,  and 
with  the  patient's  mouth  open.  The  importance  of  de- 
termining these  boundaries  may  be  noticed  in  phthisis, 
when  one  apex  is  often  found  considerably  retracted. 
Plate  VII.,  o  P. 

Anterior  Borders. —  Owing  to  the  peculiar  resonance 
of  the  sternum  and  to  the  fact  that  we  cannot  dis- 
tinguish the  sound  of  the  right  from  that  of  the  left 
lung,  it  is  impossible  to  outline  those  portions  of  the 
anterior  borders  which  underlie  the  sternum.  Plate 
IV. 

In  percussing  down  the  left  sternal  line,  we  notice  a 
dull  ins:  of  the  resonance  at  the  third  rib.  This  dullness 
is  due  to  the  underlying  heart,  and  will  be  further  men- 
tioned in  connection  with  that  organ.  On  reaching  the 
fourth  rib  there  is  a  sudden  change  from  pulmonary 
resonance  to  flatness,  which  indicates  the  transition  from 
lung  to  heart.  The  line  of  this  transition  extends  a  short 
distance  outward  along  the  fourth  rib,  and  then  turns 
perpendicularly  downward  across  the  fifth  rib.  At  the 
sixth  rib  it  turns  again  to  the  left,  and  is  lost  in  the 
lower  border.  The  line  a  to  c,  along  the  left  edge  of  the 
sternum,  indicates  the  change  from  cardiac  flatness  to 
sternal  resonance. 

Inferior  Borders. —  On  the  left  side  the  inferior  per- 
cussion border  lies  as  follows  :  — 

Axillary  line At  the  eighth  rib. 

Scapular  line At  the  tenth  rib. 

Vertebral  line At  the  eleventh  rib. 

The  position  of  this  border  in  the  mammillary  line  is 


LUNGS.  19 

often  difficult  to  establish,  owing  to  the  great  resonance 
of   the   stomach    beneath.      Ordinarily,    however,    it   is 

placed  at  the  sixth  rib. 

The  inferior  percussion  border  of  the  right  lung  stands 
as  follows  :  — 

Median  line At  base  of  xiphoid  cartilage. 

Parasternal   and  mammillary 

lines On  sixth  rib.     Sometimes  nearer 

the  upper  edge ;  sometimes 
nearer  the  lower  edge  of  the 
rib. 

Axillary  line At    the    eighth    rib.     It    may    be 

found  as  high  as  the  seventh 
intercostal  space,  or  as  low  as 
the  eighth  intercostal  space. 

Scapular  line At  tenth  rib. 

Vertebral  line At  eleventh  rib. 

The  line,  P  Q,  in  Plate  IV.,  represents  the  superior 
border  of  the  hepatic  dullness,  which  will  be  described 
elsewhere. 

It  will  be  remembered  that  these  percussion  bounda- 
ries represent  the  normal  expiratory  position  of  the  lung 
in  an  adult.  In  extreme  youth  and  in  old  age  these 
boundaries  are  differently  situated.  Plate  IX.  represents 
the  senile  type,  and  Plate  VIII.  the  infantile  type.  Thus 
(e  in  children  the  pulmonary  boundaries  may  be 
found  from  one  half  to  a  whole  interspace  higher  than  in 
an  adult,  while  in  old  age  they  are  the  same  distance 
lower. 

Moreover,  during  life  the  borders  of  the  tangs  are  con- 
tinually changing  position  with  each  act  of  respiration, 
and  with  t'\<'\-\-  change  of  the  body. 

Active  mobility  ol  the  lungs.  —  Concurrent  with  the  acts 
of  breathing,  the  inferior  borders  of  the  Lungs  arc  alter- 
nately descending  and  ascending,  so  that  their  percussion 


20  PERCUSSION   OUTLINES. 

Limits  include  a  considerable  space.     The  inspiratory  de- 
scent of  the  lower  border  is  ordinarily  : — 

In  the  right  parasternal  line     .     .     .     1£  to  2  centimeters. 
In  the  right  mammillary  line  .     .     .     2  to  3  centimeters. 

In  both  axillary  lines 3  to  4  centimeters. 

In  both  scapular  lines 2  centimeters. 

(Weil.) 

With  forced  expiration,  these  borders  will  be  retracted 
as  far  above  their  usual  position,  and  even  further  than 
they  are  lowered  by  the  fullest  inspiration.  The  amount 
of  excursion,  therefore,  between  the  position  of  fullest  ex- 
piration and  that  of  fullest  inspiration  is  : — 

In  the  mammillary  line 8^-  centimeters. 

In  the  axillary  line 9^  centimeters. 

In  the  scapular  line 7^  centimeters. 

That  portion  of  the  left  anterior  border  which  over- 
lies the  heart  also  undergoes  active  movements  during 
respiration.  With  inspiration  this  border  is  carried  for- 
ward into  the  sinus  mediastino-costalis,  so  as  to  greatly 
diminish  the  area  of  cardiac  flatness.  In  some  persons 
the  advance  may  be  so  great  as  to  almost  obliterate  the 
cardiac  flatness.  In  a  similar  way,  the  area  of  flatness 
is  noticeably  increased  during  full  expiration. 

Passive  mobility  of  the  lungs.  —  Gerhardt  found  that 
the  pneumono-hepatic  border,  when  a  man  lies  on  his 
back,  is  one  to  two  centimeters  lower  than  in  the  erect 
posture.  When  one  turns  on  to  the  right  side,  the  in- 
ferior border  of  the  left  lung  descends  by  a  distance  equal 
to  a  full  inspiration.  The  same  is  true  of  the  lower 
right  border,  when  one  lies  on  the  left  side.  These 
changes  of  position  are  called  the  passive  mobility  of  the 
lungs,  and  it  is  important  to  bear  them  in  mind  when  per- 
cussing an  invalid  in  bed. 

The  active  and  passive  mobility  of  the  lungs  are  usually 


LUNGS.  21 

diminished  or  entirely  absent  in  cases  of  emphysema  and 
pleurisy.  In  the  former  disease  the  lungs  are  perma- 
nently enlarged  and  incapable  of  retraction,  Avhile  in 
pleurisy  the  lungs  may  be  either  permanently  retracted, 
or  so  tied  up  by  adhesions  as  to  be  held  stationary. 

Notice:  The  diagram  of  percussion  boundaries,  Plate 
IV.,  does  not  portray  any  divisions  between  the  lobes. 
This  is  because  the  resonance  of  contiguous  lobes  cannot 
be  distinguished  from  each  other  under  ordinary  condi- 
tions. In  cases  of  pneumonia,  where  one  lobe  is  solidi- 
fied and  its  neighbor  is  not,  the  line  of  transition  from 
the  dullness  of  the  former  to  the  resonance  of  the  latter 
will  coincide  with  the  anatomical  sulcus.  The  careful 
delineation  of  these  lines  will  often  :is>i>t  in  removing 
doubts  between  pneumonia  and  pleurisy. 

l'ATHOLOGY. 

Pneumonia.  —  Pneumonia   does    not    produce    any 

marked  change  in  the  gross  outlines  of  the  lungs.  It 
cause-,  a  diminution  of  the  pulmonary  resonance,  how- 
ever, which  varies  in  intensity  and  extent  according  to 
the  amount  and  degree  of  infiltration,  in  catarrhal 
pneumonia,  the  dull  urea  may  be  limited  to  a  few  lobules 
only,  but  it  is  usually  impossible  to  accurately  define  the 
outline  of  such  an  urea,  because  the  transition  from  dull- 
i  i        io   the    resonance  of   neighboring   lobules   is   very 

gradual. 

When    an    entire     lobe     is    hepatized,    as     in     croupous 

pneumonia,  the  percussion  line  of  demarkation  between 
the  dull  ami  the  companion  resonant  lobe  corresponds 
to  the  anatomical  sulcus  which  separates  them.  It  is 
importanl  to  remember  thai  in  some  stages  of  pneumonia 
—  in  the  beginning  of  lobular  pneumonia,  and  during  tin; 
resolving  stage  of  croupous  pneumonia  —  we  may  obtain 
a  tympanitic  resonance  over  the  parts  which  are  relaxed 
by  disease. 


22  PERCUSSION   OUTLINES. 

Cavities.  —  Taken  by  themselves  alone,  and  judged 
by  any  or  all  of  the  signs  which  are  peculiar  to  them- 
selves, pulmonic  cavities  are  very  difficult  of  diagnosis. 
It  may  be  laid  down  as  a  safe  rule,  to  start  with,  that 
such  cavities  possess  no  pathognomonic  percussion  signs. 

Several  signs  have  been  described,  however,  and  more 
or  less  importance  has  been  attributed  to  them  by  differ- 
ent writers  ;  and  yet  a  careful  analysis  of  the  conditions 
under  which  they  may  occur  will  reveal  their  fallibility 
as  indicators  of  cavities.  These  signs  are :  the  cracked- 
pot  sound,  tympanitic  resonance,  Wintrich's  variable- 
pitch,  Gerhardt's  variable-pitch,  amphoric  resonance. 

The  cracked-pot  sound  is  obtained  by  listening  at  the 
open  mouth  of  the  patient,  while  strong  percussion  is 
made  upon  the  chest.  It  resembles  the  chinking  of 
money,  and  may  be  imitated  by  clasping  the  hands  loosely 
together  and  striking  the  back  of  one  of  them  upon  the' 
knee.  This  sound  may  be  obtained  from  the  chest,  how- 
ever, without  the  presence  of  a  cavity,  as  with  pleural  ef- 
fusion, pneumonia,  pneumo-pericardium,  and  even  upon 
healthy  persons.  Thus,  if  we  percuss  the  back  of  a 
screaming  infant,  or  of  a  thin  woman,  we  may  produce  the 
cracked-pot  sound. 

Tympanitic  Resonance.  —  The  best  observers  unite  in 
declaring  that  a  cavity  must  be  as  large  as  a  man's  fist, 
superficially  situated,  and  surrounded  by  a  certain  amount 
of  indurated  tissue,  in  order  to  give  forth  a  tympanitic 
note.  But  tympanitic  resonance  occurs  more  often  with- 
out cavities  than  with  them,  as  with  pleurisy  and  pneu- 
monia. Weil  thinks  that  not  more  than  ten  per  cent,  of 
the  cases  of  tympanitic  resonance  over  the  lungs  are  at- 
tributable to  pulmonic  cavities.  This  sign,  therefore,  has 
hut  little  value  in  itself.  It  has  gained  a  new  impor- 
tance, however,  by  certain  investigations  made  regarding 
its  pitch  under  various  conditions. 


LUNGS. 


23 


Wintrich's  Variable-pitch.  —  Wintrich  observed  that 
when  a  cavity  gave  forth  tympanitic  resonance,  the  pitch 
of  tins  resonance  could  be  raised  by  opening  the  mouth  of 
the  patient.  In  order  to  obtain  this  sign  the  cavity  must 
connect  with  a  free  bronchus.  Sometimes  the  sign  will 
appear  and  then  disappear,  by  reason  of  the  plugging  of 
the  bronchus  with  secretion.  In  such  cases  an  effort  at 
coughing  will  clear  the  tube  and  restore  the  sign.  A 
similar  change  of  pitch  on  opening  and  closing  the  mouth 
may  be  noticed  when  percussing  over  relaxed  pulmonary 
tissue,  and  also  with  the  so-called  Williams'  tracheal  tone. 
It  follows,  therefore,  that  other  possibilities  must  be 
eliminated    before    this    sign    can    decisively    indicate   a 

ea\  ity. 

Gcrhardfs  Variable-pitch.  —  Gerhardt  noticed  that  a 
cavity  which  is  oval   in   shape  and   contains   both    fluid 


Fi§f. 


Fi$.2. 


and  air,  as  in  Fig.  1,  will  give  forth  a  tympanitic  res- 
onance  which  will  vary  in  pitch  with  changes  in  the 
position  <>t"  the  patient.  Suppose  the  Long  diameter  of 
the  cavity  (<//<)  to  be  in  the  Longitudinal  axis  of  the 
body,  then  the  percussion  note  will  have  a  higher  pitch 

when  the  patient  stands,  and  a  lower  pitch  when  he  lies 
on  his   hack,  because   the  column  of  air  {a  e),  above  the 


24  PERCUSSION   OUTLINES. 

fluid,  is  shorter  in  the  former  case  (Fig.  1)  than  the 
column  (a  5)  is  in  the  latter  (Fig.  2). 

Amphoric  Resonance. — This  is  a  rare  phenomenon  with 
cavities.  In  order  for  its  production  the  cavity  must 
have  a  certain  size ;  its  inner  surface  must  be  smooth, 
and  its  walls  must  be  of  uniform  consistency.  Leich- 
tenstein  says  that  this  phenomenon  can  often  be  detected 
by  listening  to  the  chest,  while  a  second  person  per- 
cusses over  the  suspected  cavity  with  a  lead  pencil  upon 
an  ivory  pleximeter.  This  method,  he  says,  will  often 
reveal  a  cavity  when  all  other  tests  have  failed. 

To  sum  up  regarding  the  above  signs,  it  may  be  said 
that  the  cracked-pot  sound  and  tympanitic  resonance 
have  nothing  characteristic  of  a  cavity.  The  amphoric 
resonance  is  more  conclusive,  and  yet  this  sound  may  be 
obtained  over  bronchi  and  trachea. 

Wintrich's  variable-pitch  is  very  dubious.  Gerhardt's 
variable-pitch,  when  well  marked,  is  perhaps  the  most 
reliable  of  all.  Weil  says  that  in  all  cases  where  the 
pitch  was  lower  in  the  upright  position,  and  higher  on 
lying  down,  he  found  a  cavity  present.  In  cases  where 
the  pitch  became  higher  on  sitting  up,  he  found  a  cavity 
present  in  all  but  one  instance. 

Valuable  evidence  regarding  the  formation  of  a  cavity 
may  be  obtained  under  the  following  circumstances. 
During  a  prolonged  observation  of  a  dull  region  on  the 
chest,  if  the  resonance  suddenly  becomes  clearer,  or  less 
dull,  with  a  tympanitic  tinge,  then  we  may  suspect  a 
cavity,  especially  if  the  change  in  resonance  is  accompa- 
nied by  a  sudden  and  profuse  expectoration. 

As  to  the  size  and  exact  form  of  a  cavity,  almost  no 
information  can  be  obtained  under  any  circumstances. 
Thus,  amphoric  resonance,  when  present,  is  usually  asso- 
ciated with  large  cavities,  but  cases  have  occurred  where 
it  appeared  with  a  small  cavity  which  connected  freely 
with  a  bronchus. 


EMPHYSEMA.  25 

Emphysema.  —  In  emphysema  the  entire  chest  as- 
sumes permanently  the  position  of  inspiratory  expansion, 
which  varies  in  degree  according  to  the  duration  and 
amount  of  the  disease. 

Pvlmonary  Borders.  —  The  inferior  borders  are  the 
ones  chiefly  affected.  They  may  descend  as  low  as  the 
seventh  intercostal  space,  or  the  eighth  rib  in  the  mam- 
millary  line ;  the  tenth  rib  in  the  axillary  line  ;  the 
twelfth  rib  in  the  vertebral  line.  With  moderate  em- 
physema  the  sinkage  of  the  border  will  of  course  be 
proportionally  less. 

The  cardiac  border  is  advanced  so  as  to  occupy  the 
cardio-mediastinal  sinus.  By  this  means  the  area  of 
cardiac  flatness  becomes  diminished  to  a  narrow  zone  at 
the  level  of  the  sixth  rib,  or  it  may  be  entirely  obliterated 
in  excessive  cases. 

It  will  be  remembered  that,  in  old  age,  the  diaphragm, 
heart,  and  inferior  borders  of  the  lungs  always  stand 
at  a  lower  level  than  in  adult  life.  Hence,  in  diagnos- 
ing emphysema,  one  should  always  compare  the  amount 
of  pulmonary  expansion  with  the  age  of  the  patient.  If 
the  lower  border  in  a  person  over  sixty- live  years  of  age 
reach  no  further  than  the  seventh  rib  in  the  mam  miliary 
line,  the  condil  ion  is  normal. 

Another  sign  of  emphysema  is  the  diminution  or  ab- 
sence of  both  the  active  and  passive  mobility  of  the  infe- 
rior borders  of  the  lungs.  We  have  seen  cases  where  the 
most  energetic  efforts  at  respiration,  in  various  positions 

of  the  hoily,  failed  to  change  the  percussion   borders. 

The  apices  of  the  lungs  are  often  raised  to  a  higher 
elevation  —  five  to  six  centimeters  —  above  the  clavi- 
cles, in  which  case  the  superior  borders  are  correspond- 
ingly higher. 

Hepatic  Boundaries.  —  The  outlines  of  the  liver  are 
considerably  changed  in  emphysema.       The  pneumono* 


26  PERCUSSION   OUTLINES. 

hepatic  border  is  always  lower,  and  the  apparent  size  of 
the  liver  will  then  depend  upon  its  relation  to  the  ex- 
panded lung.  If  the  liver  remains  in  its  normal  posi- 
tion, or  nearly  so,  then  the  area  of  hepatic  flatness  will 
be  necessarily  diminished.  On  the  other  hand,  if  the 
liver  be  simultaneously  depressed  by  a  descent  of  the  dia- 
phragm, then  the  area  of  flatness  may  remain  normal  in 
size  or  even  appear  increased. 

Pleurisy.  —  The  changes  produced  by  pleurisy  in  the 
percussion  boundaries  of  the  lungs  will  vary  according 
to  the  character,  seat,  and  extent  of  the  affection.  A 
simple  dry  pleurisy  with  adhesions  may  leave  the  pul- 
monary boundaries  little  affected,  except  as  regards  their 
mobility.  Thus  firm  adhesions  may  interfere  with  the 
respiratory  expansion,  and  also  with  the  passive  move- 
ments which  normally  accompany  changes  of  the  position 
of  the  body.  Again,  thick  deposits  of  pleuritic  mem- 
branes will  produce  a  general  diminution  of  vesicular 
resonance. 

Pleurisy  with  Effusion.  —  With  an  encysted  pleuritic 
effusion,  an  area  of  dullness  (or  flatness,  with  a  large 
amount  of  fluid)  will  be  found,  which  varies  in  shape  and 
position  according  to  the  size  and  situation  of  the  exuda- 
tion. No  general  law  can  be  laid  down  for  such  cases, 
and  the  dullness  thus  observed  must  be  distinguished  from 
that  which  accompanies  consolidation  of  the  lung,  by 
such  other  evidence  as  can  be  obtained  through  auscul- 
tation and  palpation. 

An  accumulation  of  free  fluid  in  the  pleural  cavity(pleu 
ritic  effusion,  empyema,  hydrothorax,  kaematothorax,) 
causes  marked  changes  in  the  percussion  outlines  of  the 
pulmonary  borders.  As  the  fluid  gradually  forms,  it 
gathers  at  the  bottom  of  the  chest,  and  the  lung  begins 
to  contract  in  volume.  Let  it  be  said  here,  that  a  lung 
which  retains  its  integrity  and  elasticity  cannot  be  pressed 


EMPHYSEMA.  27 

upon,  or  compressed  by,  an  encroaching  effusion,  until  it 
is  completely  collapsed,  and  the  amount  of  fluid  present. 
is  excessive.  The  lung  simply  contracts  in  volume,  but 
it  still  sustains  the  weight  of  the  diaphragm  plus  that  of 
the  fluid  in  the  same  manner  that  it  previously  sustained 
the  diaphragm  alone. 

Assoon  as  sufficient  effusion  has  collected  for  detec- 
tion by  percussion  — 200  cc.  according  to  Seitz  —  we 
obtain  over  the  fluid  a  ilat  sound,  and  varying  degrees  of 
dullness  over  the  collapsing  lung  above.  The  line  of  de- 
markation  between  the  flatness  of  the  fluid  and  the  dull 
resonance  of  the  lung  is  usually  well  marked.  The 
shape  and  position  of  this  line,  however,  have  been  the 
subject  of  much  controversy.  Most  German  writers  fol- 
low Wintrich  in  declaring  that  this  line  stands  generally 
highest  behind  in  the  neighborhood  of  the  spinal  column, 
and  thence,  descends  obliquely  to  the  sternum.  Some 
allow  that  the  line  may  sometimes  be  horizontal,  but  they 
think  that  this  shape  is  exceptional,  and  due  to  the  posi- 
tion maintained  by  the  patient  during  the  early  stage 
of  the  effusion.  Thus,  if  the  patient  lie  quietly  in  bed 
during  that  stage,  the  fluid  will  assume  a  level  corre- 
sponding to  that  position.  Subsequently,  as  the  patient 
arises  and  walks  about,  the  fluid  is  prevented  from  re- 
accommodation  by  adhesions,  and  hence  the  obliquity  of 
its  surface.  Among  the  French,  Piorry  and  his  followers 
teach  that  an  effusion  ordinarily  adjusts  itself  to  a  hori- 
zontal level  for  all  positions  of  the  body.  On  the  other 
band,  Damoiseau  declined  that  the  line  in  question  is 
never  horizontal,  but  is  more  or  less  parabolic  with  its 
summit  in  the  axillary  line,  and  its  branches  extending 
down  on  either  side  to  the  sternum  and  vertebral  column. 

In   our  own    experience,  we    have  never   seen    a  pleural 

effusion  (pneumo-hydrothorax  excepted  )  which  presented 
a  horizontal  line  of  demarcation,  nor  do  we  obtain  a  line 


28  PERCUSSION   OUTLINES. 

like  that  described  by  the  Germans.  On  the  contrary, 
we  find  that  the  position  assumed  by  an  effusion  is  that 
which  was  first  described  by  Prof.  Calvin  Ellis,  of  Boston. 
This  observer  discovered  that  with  small  and  medium 
effusions  the  line  of  flatness  begins  lowest  behind  at  the 
vertebral  column.  Thence  it  ascends  obliquely  across  the 
back,  in  a  letter  S  curve,  to  the  axillary  region,  where  it 
reaches  its  highest  point.  Then  it  advances  to  the  ster- 
num with  a  slight  inclination  downward.  With  large 
effusions,  which  fill  the  chest  to  the  second  rib  or  higher, 
this  curve  disappears,  and  the  line  becomes  more  nearly 
horizontal,  and  more  difficult  to  trace.  As  absorption 
takes  place,  however,  or  the  fluid  is  removed  by  aspira- 
tion, the  curve  reappears  and  passes  through  retrograde 
phases  corresponding  in  shape  to  those  of  the  earlier 
stages. 

It  is  sometimes  difficult  to  trace  the  curve  on  the 
back,  owing  to  the  great  dullness  of  the  lung  immediately 
above  the  effusion.  This  dullness  is  often  due  to  a  lack 
of  proper  ventilation  of  the  lower  lobe,  especially  when 
the  patient  is  lying  down,  and  therefore  one  should  not 
attempt  to  trace  the  line  until  the  patient  has  taken 
several  deep  breaths  and  thus  thoroughly  filled  the  lung. 
In  Fig.  III.  it  will  be  seen  that  we  have  drawn  a  hori- 
zontal line,  A  B,  from  the  summit  of  the  curve  to  the 
vertebral  column,  and  have  thereby  inclosed  a  rough, 
triangular  space,  ABC.  This  space  corresponds  to 
the  lowest  portion  of  the  lung,  and  is  especially  liable  to 
be  obscured  by  dullness.  The  lung  lies  here  in  contact 
with  the  chest  wall,  but  its  resonance  may  be  so  dull 
as  to  escape  detection  unless  careful  percussion  is  made 
and  the  patient  breathes  deeply.  We  have  termed  this 
space  the  dull  triangle,  and  its  recognition  is  of  vital 
importance.  Heitler,  in  Vienna,  has  observed  this  same 
triangular  space  of   resonance,  and  has  likened  it  to  a 


PLEURISY. 


29 


monk's  hood  cut  longitudinally  through  the  centre  and 
hanging  apex  down.  Rosenbach,  of  Breslau,  has  also 
noticed  that  the  resonance  of  this  portion  of  the  back  in 
pleurisy  will  often  clear  up  on  exercise  or  by  breathing, 
and  such  clearing  up  of  the  resonance  of  a  dull  back  he 


Fig  3. 


baa  made  distinctive  between  pleurisy  and  pneumonia. 
The  Bame  condition  of  things  obtains  in  hydrothorax,  but 

in  some  cases  the  triangle  may  be  still  more  dull,  and  re- 
quire careful  auscultation  and  percussion,  owing  to  the 
(edema  of  the  limy;  itself. 


CHAPTER  IV. 

HEART. 

Anatomy. — The  heart,  inclosed  in  the  pericardial  sac, 
lies  in  an  oblique  plane  extending  from  the  right  side 
above  downward  and  forward  toward  the  left  side.  It 
is  situated  partly  behind  the  sternum  and  partly  behind 
the  right  and  left  costal  cartilages.  Its  highest  point, 
the  upper  border  of  the  left  auricle,  corresponds  to  a  line 
connecting  the  lower  borders  of  the  sternal  insertion  of 
the  second  pair  of  ribs.  Its  lowest  point  is  at  the  middle 
of  the  upper  border  of  the  sixth  left  costal  cartilage. 
The  heart  extends  eight  or  nine  centimeters  to  the  left, 
and  four  or  five  centimeters  to  the  right,  of  the  middle 
line  of  the  sternum.  We  distinguish  in  the  heart  in 
relation  to  the  chest  wall,  a  right,  a  lower,  and  a  left 
border.  The  right  border  (Plate  I.,  M  N)  is  formed  by 
the  right  auricle,  and  runs  in  a  line  curving  outward  two 
to  three  centimeters  beyond  the  right  edge  of  the  ster- 
num, from  the  middle  of  the  second  right  intercostal 
space  to  behind  the  sternal  end  of  the  fifth  right  costal 
cartilage. 

The  lower  border  N  O,  is  formed  by  the  right  ventricle, 
and  extends  from  the  sternal  end  of  the  fifth  right  costal 
cartilage  in  a  slightly  descending  line  to  the  fifth  left  in- 
tercostal space,  where  it  meets  with  the  left  border  in  the 
mammillary  line,  or  a  trifle  inside  it. 

The  left  border  P  o,  runs  in  a  convex  curve  from  the 
second  left  intercostal  space  downward  and  outward  to 


HEART.  31 

unite  with  the  left  end  of  the  lower  border  at  the  apex  of 
the  heart. 

By  far  the  greater  portion  of  the  heart  is  covered  by 
lung  ;  only  a  segment  of  the  organ  belonging  exclu- 
sively to  the  right  ventricle  lies  directly  against  the 
chest  wall  ;  this  segment  is  bounded  below  by  the  lower 
edge  of  the  heart,  and  on  the  right  and  left  by  the  di- 
verging anterior  borders  of  the  right  and  left  lung. 
The  size  and  shape  of  this  parietal  portion  of  the  heart 
depends  wholly  on  the  course  of  the  anterior  edges  of  the 
lungs,  which  have  been  fully  described  elsewhere.  Dur- 
ing quiet  respiration  it  has  a  four-sided  shape  (Plate  I.). 
The  right  border  is  bounded  by  the  front  edge  of  the 
right  lung  running  near  the  left  border  of  the  sternum 
from  the  level  of  the  fourth  to  the  sixth  (or  seventh) 
costal  cartilage;  the  upper  border  is  bounded  by  that 
part  of  the  incisura  cardiaca  behind  the  fourth  left  costal 
cartilage  running  outward  to  the  fourth  intercostal  space  : 
the  outer  side  is  bounded  by  the  more  vertical  portion  of 
the  anterior  border  of  the  left  lung,  running  in  a  convex 
curve  outward  from  the  fourth  intercostal  space  to  the 
sixth  rib.  The  upper  and  outer  borders  unite  with  no 
sharp  line  of  division  between  them,  and  even  in  quiet 
respiration  exhibit  manifold  differences  in  their  course. 
This  uncovered  space  is  crossed  diagonally  by  the  left 
pleura,  in  such  a  way  that  only  in  the  lower  portion  does 
the  pericardium  come  in  actual  contact  with  the  sternum. 

I'ICItCUSSIOX. 
The  heart  gives  forth  a  Hat  sound  where  it  lies  directly 
against  the   chest  wall.      The  boundaries  of   this  region  of 
flatness  above,  to  the    right  and  left  follow  in  general  the 

course  of  the  anterior  edges  of  the  Lungs,  and  correspond 
to  those  lines  in  which  the  transition  from  the  clear  ve- 
sicular sound  to  the  tint  sound  occurs.      The  lower  border 


32  PERCUSSION   OUTLINES. 

of  the  heart  cannot  be  defined  by  percussion,  because 
the  flat  sound  of  the  heart  is  indistinguishable  from  that 
of  the  left  lobe  of  the  liver.  The  lower  border,  therefore, 
from  the  point  where  the  liver  meets  it  to  the  apex  of  the 
heart,  must  be  drawn  arbitrarily,  as  described  later. 

We  recognize  an  area  of  absolute  flatness  and  one  of 
relative  dullness  in  the  percussion  of  the  heart.  It  is 
perhaps  unnecessary  to  add  that  there  are  great  diversities 
of  opinion  in  regard  to  the  size  and  shape  of  this  abso- 
lute flatness,  but  we  have  generally  found  the  following 
dimensions  to  be  most  nearly  correct. 

In  adults,  the  absolute  cardiac  flatness  is  an  irregular 
quadrangle  (Plate  IV.,  ABC  D).  The  right  border  A  C  is 
formed  by  the  left  edge  of  the  sternum  from  the  level  of 
the  fourth  to  the  sixth  or  seventh  rib  ;  the  upper  border 
A  B  runs  behind  the  fourth  costal  cartilage  outward  and 
downward,  and  meets  with  the  left  side  of  the  quadrangle 
at  an  obtuse  angle ;  the  latter,  B  D,  runs  more  vertically 
downward  to  the  sixth  rib,  where  it  meets  with  the  lower 
side  of  the  quadrangle,  C  D,  at  an  acute  angle.  While  the 
inner  and  lower  sides  have  a  tolerably  constant  length, 
and,  as  a  rule,  measure  five  to  six  centimeters,  the  upper 
and  outer  sides  show  manifold  differences  in  their  course 
which  it  appears  superfluous  to  mention  in  detail.  We 
need  only  say,  that  when  the  upper  side  deviates  more 
from  a  horizontal  course,  or  the  outer  side  becomes  less 
vertical  in  its  direction,  the  region  of  absolute  flatness 
becomes  smaller,  and  its  form  more  triangular.  The 
right,  the  upper,  and  the  left  borders  of  this  space  are 
readily  obtained  by  gentle  percussion.  As  the  lower 
border,  in  the  greater  part  of  its  course,  overlies  the  left 
lobe  of  the  liver,  we  can  only  obtain  it  by  determining 
the  point  on  the  right,  where  the  cardiac  and  hepatic 
flatness  meet,  and  the  position  of  the  apex,  and  then  join 
these  two  by  a  straight  line.     It  is  only  in  rare  instances 


HEART.  33 

that  the  heart  extends  beyond  the  left  lobe  of  the  liver, 
and  in  such  cases  the  cardiac  flatness  is  bounded  by  the 
tympanitic  sound  of  the  stomach. 

Notice  :  Comparison  of  the  absolute  cardiac  flatness 
and  the  portion  of  heart  uncovered  by  lung  shows  a  dif- 
ference only  in  two  places.  (1.)  The  right  border  of  the 
cardiac  flatness  lies  at  the  left  edge  of  the  sternum,  the 
front  edge  of  the  right  lung  on  the  other  hand  is  half  way 
to  the  right  of  this  line;  the  cause  of  this  difference  is 
the  oft  mentioned  vibration  of  the  sternum.  (2.)  The 
thin  lingula  pulmonis  overlying  the  cardiac  apex  cannot 
be  mapped  out. 

The  shape  of  the  heart's  flatness,  described  and  fig- 
ured in  Plate  IV".,  A  B  C  D,  is  normal  for  healthy  people 
from  the  middle  of  the  second  to  the  end  of  the  sixth 
decade.  In  childhood,  and  also  in  old  age,  the  shape  and 
size  of  this  area  is  somewhat  different.  In  children,  the 
absolute  flatness  of  the  heart  begins  at  the  third  rib,  and 
extends  to  the  mammillary  line  (Plate  VIII.),  the  apex 
impulse  being  frequently  met  with  in  the  fourth  intercos- 
tal space.  The  absolute  cardiac  flatness  in  children,  there- 
fore, is  found  to  be  relatively  greater  and  .situated  higher 
up  than  in  middle  age.  In  old  age,  on  the  other  hand, 
the  opposite  condition  is  observed  (Plate  IX.).  Here  the 
area  of  cardiac  flatness  is  smaller,  it  does  not  begin  till 
t  to  tin;  fifth  rib.  and  it  reaches  outward  to  a  less 
extent  ;  its  height  and  breadth  amount  to  about  four  or 
five  centimeters.  The  cause  of  this  diminution  in  the 
size  of  the  absolute  flatness  is  the  entrance  of  the  border 
of  the  left  lung  into  the  sinus-niediastino-costalis  depend- 
ent on  senile  emphysema,  which  may  be  regarded  as  a 
normal  senile  condition.  We  need  hardly  call  special  at- 
tention to  the  fact  that  these  three  types  of  cardiac  llat- 
giveil  for  childhood,  adult  life,  and  old  age,  are  not 
sharply  defined,  but  rather  gradually  run  into  each  other. 
3 


34  PERCUSSION   OUTLINES. 

Active  Mobility  of  the  Absolute  Cardiac  Flatness. 

The  boundaries  of  absolute  flatness  are  found  in  the 
shape  and  extent  described  above,  when  the.  person  exam- 
ined maintains  the  dorsal  decubitus  and  breathes  nat- 
urally. These  boundaries,  however,  suffer  certain  respi- 
ratory displacements,  and  also  certain  displacements  in 
changes  of  the  position  of  the  body ;  in  other  words, 
they  have  a  considerable  active  and  passive  mobility. 

The  upper  border  descends  two  to  three  centimeters,  the 
left  border  moves  about  as  much  to  the  right,  and  the 
right  border  remains  unchanged  ;  so  that  the  absolute 
cardiac  flatness  is  diminished  perhaps  one  third.  With 
the  deepest  possible  inspiration,  only  a  strip  of  flatness 
the  breadth  of  the  finger  can  be  discovered  close  to  the 
sternum,  or  it  may  be  replaced  by  a  clear  pulmonary  res- 
onance at  the  left  edge  of  the  sternum. 

The  expiratory  displacement  of  the  borders  averages 
two  centimeters  outward  and  as  much  upward. 

Passive  Mobility. 

When  the  individual  examined  changes  from  the 
dorsal  decubitus  to  the  upright  position,  no  displacement 
of  the  cardiac  boundaries  follows.  On  the  other  hand, 
when  one  is  in  the  right  lateral  decubitus  the  same  effect 
is  observed  on  the  left  and  upper  boundaries  as  in  the 
deepest  possible  inspiration  ;  and  very  frequently  a  re- 
gion of  flatness  is  found  on  the  right  of  the  sternum, 
between  it  and  the  parasternal  line,  at  the  level  of  the 
fifth  or  sixth  rib,  and  even  as  high  as  the  fourth  intercos- 
tal space.  This  right-sided  absolute  cardiac  flatness  is 
separated  from  that  on  the  left  side  by  the  clear  sound 
of  the  sternum  ;  and  it  may  be  enlarged  by  forced  ex- 
piration. The  change  from  the  dorsal  to  the  left  lateral 
decubitus  involves  an  excursion  of  the  upper  and  left 


HEART.  35 

borders  in  the  same  way :  the  left  border,  however,  moves 
somewhat  further  toward  the  left  than  in  forced  expira- 
tion. 

Relative  Cardiac  Dullness. 

The  size  and  shape  of  the  relative  dullness  of  the  heart, 
that  is,  where  it  is  overlaid  by  lung,  in  most  healthy  in- 
dividuals between  the  middle  of  the  second  and  the  end 
of  the  sixth  decade  is  represented  by  the  line  A  I  k, 
Plate  IV. 

The  right  border  of  the  figure  is  formed  by  the  left 
edge  of  the  sternum  from  the  level  of  the  third  to  the 
sixth  intercostal  space. 

Above  and  toward  the  left  the  dullness  is  shut  in  by  a 
curved  line,  with  its  convexity  directed  outward,  I  k. 
The  upper  more  horizontal  portion  of  this  curve  runs 
through  the  third  intercostal  space,  and  over  the  fourth 
rib  obliquely  outward  and  downward.  The  lower  outer 
portion  of  the  curve  runs  in  a  nearly  vertical  line  from  the 
fourth  intercostal  space  to  the  sixth  rib,  just  inside  the 
mammillary  line. 

Notice:  1.  The  percussion  boundary  corresponds  to 
the  anatomical  on  the  left  only.  All  that  portion  of  the 
heart  lying  beneath  the  sternum  and  behind  the  left  third 
rib  and  second  intercostal  space  cannot  be  brought  out. 

-.  The  boundary  of  the  cardiac  dullness  above  and  to 
tht;  left  is  parallel  to  that  of  the  cardiac  flatness,  and  is 
removed  two  to  three  centimeters  from  the  same. 

1  Mobility  of  the  Relative  Heart's  Dullness. 

The  above  boundaries  suffer  displacement  just  as  do 
those  of  the  absolute  flatness  on  deep  inspiration  and 
changes  of  position  ;  and  this  is  about  the  same  in  kilid 
and  extent  as  in  the  absolute  flatness.  They  maintain 
the  same  relation  to  each  other,  therefore,  as  in  quiet 
respiration  or  the  dorsal  decubitus.  Two  points  deserve 
to  be  mentioned,  however. 


36  PERCUSSION   OUTLINES. 

First,  In  those  cases  where  the  absolute  flatness  quite 
disappears  on  deep  inspiration,  there  still  remains  on 
the  left  edge  of  the  sternum,  from  the  level  of  the  fourth 
to  the  sixth  rib,  a  region  of  relatively  dull  sound  several 
centimeters  broad. 

Second,  When  absolute  flatness  appears  on  the  right 
of  the  sternum  in  the  right  lateral  decubitus,  a  zone  of 
dull  resonance  one  or  two  centimeters  in  width  may  also 
be  found  surrounding  this  flatness.    (Weil.) 

PATHOLOGY. 

Diminution  or  disappearance  of  flatness  in  the  cardiac 
area  is  observed:  1.  In  congenital  dexiocardia ;  2.  In 
left-sided  pneumothorax  with  great  expansion  of  the  chest 
and  displacement  of  the  neighboring  organs ;  3.  In  ex- 
tensive emphysema  ;  4.  In  pneumo-pericardium. 

In  congenital  dexiocardia,  usually  also  in  pneumo- 
thorax of  the  left  side,  a  cardiac  flatness  may  be  demon- 
strated on  the  right  side  between  the  right  edge  of  the 
sternum  and  the  right  parasternal  or  mam  miliary  line 
between  the  third  or  fourth  and  the  sixth  rib  ;  while  in 
great  emphysema  and  pneumo-pericardium  there  is  en- 
tire absence  of  all  cardiac  flatness.  In  the  extremest 
degrees  of  emphysema  there  is  everywhere  above  the 
lower  border  of  the  lungs,  even  on  the  left  side,  a  loud, 
clear  pulmonic  sound.  In  less  pronounced  cases  absolute 
flatness  may  be  absent,  but  a  narrow  zone  of  relative 
dullness  may  be  demonstrated  along  the  left  edge  of  the 
sternum  in  the  fifth  and  sixth  intercostal  space.  In  the 
slightest  degrees  of  emphysema,  both  relative  and  abso- 
lute cardiac  flatness  can  still  be  outlined,  though  they  are 
smaller  and  are  situated  lower  down  than  in  normal 
conditions. 

The  diminution  of  the  cardiac  area  of  flatness  in  em- 
physema is  explained  by  the  expansion  of  the  lung  into 


HEART.  37 

the  sinus  mediastino-costalis.  A  disappearance  of  the 
absolute  cardiac  flatness  may  occasionally  be  caused  by 
the  transmission  of  resonance  from  the  neighboring  lung, 
when  the  intercostal  spaces  are  very  narrow,  and  the  cos- 
tal cartilages  are  very  elastic. 

In  the  rare  cases  where  free  gas  is  present  in  the  peri- 
cardial sac,  a  clear  tympanitic,  almost  metallic,  sound  is 
obtained  over  the  heart  when  the  patient  is  lying  on  the 
back.  When  the  patient  sits  up  or  bends  forward  the 
sound  over  the  lower  portion  of  the  above  tympanitic 
region  is  dulled  because  the  heart  and  any  fluid  pres- 
ent in  the  pericardium  sinks  forward  and  downward. 

Increase  of  the  Cardiac  Flatness. 

In  by  far  the  greater  number  of  cases,  this  is  due  to 
hypertrophy  and  dilatation  of  the  whole  heart,  or  portions 
of  the  same,  or  to  the  presence  of  fluid  in  the  pericardium. 
Again,  when  the  heart  is  of  normal  size,  and  the  pericar- 
dium does  not  contain  fluid,  the  cardiac  dullness  may 
appear  to  be  enlarged  upward  to  the  left,  or  toward  the 
right,  or  in  fact  in  all  directions,  by  reason  of  solidifica- 
tion or  retraction  of  the  pulmonary  borders.  It  is  not 
possible  to  distinguish  by  means  of  percussion  alone  which 
part  of  the  dullness  belongs  to  the  heart,  and  which  to  the 
unaei.it.  d  lung  (or  fluid  collected  in  the  sinus  mediastino- 
costalis). 

The  form  of  cardiac  dullness  varies  according  as  the 
left  oi-  right  ventricle  is  especially  implicated  in  the  dila- 
tation and  hypertrophy. 

In  hypertrophy  of  the  left  ventricle  the  boundaries  of 
both  the  absolute  flatness  and  relative  dullness  are  moved 
chiefly  to  the  hit  and  downward,  more  rarely  upward, 
while  the  right  border  remains  at  the  left  edge  of  the 
sternum  or  near  if.  With  a  moderate  increase  of  volume, 
as   from    arterio  -clm-osis,  the  absolute  flatness   may  begin 


38  PERCUSSION   OUTLINES. 

at  the  third  rib,  and  extend  three  or  four  centimeters 
beyond  the  mammillary  line  at  the  fifth  rib.  While,  for 
example,  in  insufficience.  of  the  aortal  valves  and  conse- 
quent high  degree  of  hypertrophy  and  dilatation  of  the 
left  ventricle,  the  upper  boundary  may  be  normal,  and 
the  left  may  reach  into  the  anterior  axillary  line. 

In  dilatation  and  hypertrophy  affecting  chiefly  the  right 
side  of  the  heart,  the  upper  borders  of  both  absolute 
flatness  and  relative  dullness  are  normal,  the  left  border 
extends  but  slightly  outward,  and  the  right  border  either 
remains  at  the  left  edge  of  the  sternum,  or,  where  the  di- 
latation is  excessive,  a  new  area  of  dullness  on  the  right 
is  met  with,  divided  from  the  normal  area  by  the  resonant 
sternum.  This  may  begin  as  high  as  the  fourth  costal 
cartilage  on  the  right  edge  of  the  sternum,  and  at  the 
level  of  the  fifth  and  sixth  costal  cartilages  extend  one 
and  a  half  to  two  centimeters  beyond  it. 

The  displacements  caused  by  respiratory  movements 
and  changes  of  position  with  hypertrophy  are  more  con- 
siderable than  in  the  normal  condition.  During  a  deep 
inspiration  the  absolute  cardiac  flatness  suffers  a  consider- 
able decrease  in  extent  toward  the  left,  and  in  decubitus 
on  the  right  side,  not  only  does  the  same  phenomenon 
occur,  but  in  addition  there  is  found  absolute  flatness  on 
the  right  of  the  sternum.  Change  from  the  prone  to 
the  upright  position  of  the  body  does  not  alter  the  boun- 
daries. 

With  pleuritic  effusion  on  the  left  side  the  heart  is  dis- 
placed to  the  right,  and  with  excessive  accumulation  of 
fluid  may  be  carried  as  far  as  the  right  axillary  line. 

With  effusion  on  the  right  side  the  heart  is  carried  to 
the  left,  and  may  reach  to  the  left  axillary  line. 

With  excessive  distention  of  the  abdomen,  either  by 
ascites,  tumors,  or  tympanites,  the  heart  is  pushed  up- 
ward.    In  a  case  of  great  ascites,  confining  the  patient 


PERICARDIUM.  39 

upon  the  left  side,  we  found  the  cardiac  impulse  at  the 
third  intercostal  space  in  the  left  axillary  line.  The  im- 
pulse presented  a  peculiar  intermittency,  coinciding  with 
the  respiratory  movements,  and  was  very  strong  during 
expiration,  while  it  disappeared  with  full  inspiration. 

The  mobility  of  the  cardiac  boundaries  may  be  lim- 
ited by  pericardial  and  pleural  (sinus  inediastino-costalis) 
adhesions. 

PERICARDIUM. 

Anatomy.  — The  external  or  parietal  layer  of  the  peri- 
cardium is  the  only  one  presenting  any  interest  to  us. 
It  corresponds  neither  in  form  nor  volume  with  the  inner 
la  er  covering  the  heart,  but  is  so  much  broader  than 
the  latter,  that  even  wdien  the  heart  is  moderately  filled 
with  blood,  it  will  still  hold  six  ounces  of  water  without 
being  extremely  distended.  (LuSCHKA.)  The  physio- 
logical purpose  of  this  arrangement  is  evident,  and  in 
pathological  conditions  it  affords  room  for  the  dilatation 
and  hypertrophy  of  the  heart  which  are  compensatory  to 
valvular  lesions,  emphysema,  and  so  forth.  The  peri- 
cardium reaches  beyond  the  base  of  the  heart  up  to  the 
middle  of  the  first  costal  cartilage  on  the  right  side,  and 
on  the  left  to  the  middle  of  the  second  costal  cartilacre. 
It  extends  below  on  the  right  to  the  mam  miliary  line  in 
the  fifth  intercostal  space,  and  on  the  left  to  the  sixth 
rib  at  least  in  the  mamniillary  line.  It  is  capable  of  some 
distention  beyond  these  points. 

l'A  THOLOGY. 

Fluid  in  the  pericardium  collects  in  the  lowermost  part 
first;  and  Iiotch,  basing  his  conclusions  on  a  series  of 
injections,  claims  that  flatness  in  the  fifth  right  inter- 
costal Bpace,  three  centimeters  from  the  edge  of  the 
sternum,  is  diagnostic  of  this  condition.  The  figure  ob- 
tained by  percussion  is  triangular,  with  a  broad  base 
below  and  a  blunt  apex  above. 


40  PERCUSSION  OUTLINES. 

With  moderate  collections  of  fluid,  the  blunt  apex  of 
the  triangle  is  found  in  the  third  or  second  intercostal 
space,  near  the  left  edge  of  the  sternum.  It  runs  from 
here  obliquely  downward,  and  to  the  right  as  far  as  the 
sixth  rib  in  the  sternal  or  parasternal  line,  and  to  the  left 
beyond  the  mammillary  line. 

If  the  fluid  is  very  abundant,  the  apex  may  be  situated 
at  the  manubrium  sterni,  while  the  base  reaches  from  the 
right  mammillary  line  at  the  level  of  the  sixth  intercos- 
tal space,  to  the  left  axillary  line  at  the  height  of  the 
seventh  rib  or  even  seventh  intercostal  space.  The  area 
of  absolute  flatness  is  said  to  be  greater  in  the  erect  than 
in  the  prone  position,  and  if  this  be  true  it  forms  a  most 
important  point  in  the  differentiation  of  pericardial  ef- 
fusion from  enlarged  heart. 


CHAPTER  V. 

LIVER. 

Anatomy.  —  Three  quarters  of  the  liver  lie  in  the  right 
half  of  the  upper  abdomen.  This  includes  the  lobus 
dexter,  lobus  Spigelii,  and  generally  the  entire  lobus 
quadratus.  The  boundary  between  the  right  and  left 
lobes  lies,  in  many  cases,  in  the  median  line,  but  it  may 
be  a  finger-breadth  to  the  right  of  the  same.  The  left 
lobe  pushes  in  between  the  stomach  and  that  portion  of 
the  diaphragm  upon  which  rests  the  heart.  It  extends 
five  to  six  centimeters  to  the  left  of  the  median  line. 

The  upper  border  of  the  liver  is  a  curved  line  corre- 
sponding to  the  arch  of  the  diaphragm.  Its  highest  point 
is  in  the  right  mammillary  line,  where  it  stands  on  a 
level  with  the  fifth  pair  of  ribs  in  front,  and  with  the 
ninth  dorsal  vertebra  behind.  At  the  end  of  expiration 
it  is  five  centimeters  higher  than  the  pneti mono-hepatic 
border. 

The  lower  edge  of  the  liver  begins  at  the  eleventh  rib 
in  the  vertebral  line.  It  runs  along  this  rib  to  the  scap- 
ular line,  when  it  tarns  obliquely  upward  and  Forward, 
and  emerges  from  beneath  the  costal  arch  in  the  mani- 
millary  line,  at  the  level  of  tin'  tenth  costal  cartilage. 
It  then  crosses  the  epigastrium,  meeting  tie'  median  line 
of  the  body  between  the  upper  and  middle  thirds  <>f  the 
distance;  from  the  umbilicus  to  the  apex  of  the  xiphoid 
cartilage.  It,  disappears  behind  the  left  costal  arch  be- 
tween the  hit  mammillary  and  parasternal  lines. 


42  PERCUSSION   OUTLINES. 


PERCUSSION. 

The  liver  presents  two  percussion  areas  and  three 
borders  for  consideration  —  the  first  area  is  the  portion 
covered  by  lung ;  and  it  gives  a  dull  resonance  on  strong 
percussion.  The  second  area  is  the  lower  part  of  the 
liver,  which  is  not  covered  by  lung,  but  lies  in  actual 
contact  with  the  chest  wall.  Here  we  obtain  a  flat  sound 
on  percussion. 

The  superior  border  corresponds  to  the  arch  of  the  dia- 
phragm, as  previously  remarked.  Near  the  vertebral 
column  it  is  impossible  to  outline  this  border,  owing  to 
the  resonance  of  the  intervening  lung.  On  the  sides  and 
in  front  it  can  usually  be  made  out  with  sufficient  ac- 
curacy for  practical  purposes.  (Plate  IV.,  P  Q.)  With 
a  very  thick  lung,  however,  or  with  emphysema,  it  is  im- 
possible to  detect  it.  That  portion  of  the  superior  bor- 
der which  underlies  the  heart  cannot  be  distinguished 
because  there  is  no  difference  between  hepatic  and  car- 
diac flatness. 

The  inferior  border  is  more  accessible,  and  can  gene- 
rally be  made  out  by  light  percussion.  It  is  indicated 
by  the  transition  from  hepatic  flatness  to  intestinal  and 
gastric  resonance.  When  the  intestines  and  stomach 
are  very  resonant  the  percussion  must  be  very  light. 

The  pneumono -hepatic  border  separates  the  hepatic 
flatness  from  the  pulmonic  resonance,  and  has  already 
been  described.  Irrespective  of  the  actual  size  of  the 
liver,  the  area  of  hepatic  flatness  will  depend  upon  the 
position  of  this  border,  and  therefore  will  diminish  with 
inspiration  and  emphysema,  and  be  increased  by  expira- 
tion or  other  shrinkage  of  the  lung. 

Gall  Bladder.  —  The  gall  bladder  ordinarily  lies 
beneath  the  liver,  and  is  inaccessible  to  palpation  or  per- 
cussion.    Let  the  exit  of  bile  be  obstructed,  however, 


LIVER.  43 

and  the  gall  bladder  becomes  distended  by  accumulated 
secretion,  and  it  will  pi-oduce  a  well-defined  tumor.  In 
such  cases  the  tumor  appears  at  the  angle  formed  by  the 
junction  between  the  lower  border  of  the  liver,  as  it 
emerges  from  the  costal  arch,  and  the  outer  border  of  the 
rectus  abdominis  muscle.  The  dull  area  is  then  usually 
pear-shaped,  and  may  be  defined  by  the  resonant  intes- 
tines about  it. 

PATHOLOGY. 

Changes  in  the  size  of  the  liver  are  often  very  difficult 
to  determine  by  percussion,  and  even  when  variations  in 
the  extent  of  hepatic  flatness  are  detected  it  is  still  diffi- 
cult to  decide  whether  such  variations  are  due  to  modifi- 
cations of  the  liver  itself  or  of  the  neighboring  organs. 
A  diminution  of  the  area  of  hepatic  flatness  may  be  pro- 
duced by  acute  or  chronic  atrophj'  of  the  liver.  It  may 
also  he  due  to  the  intrusion  of  coils  of  intestine  between 
the  liver  and  abdominal  wall.  Tympanites,  ascites,  ova- 
rian ami  uterine  tumors  will  produce  the  same  result  by 
pushing  the  liver  further  up  behind  the  lung.  Emphy- 
sematous enlargement  of  the  lung,  by  lowering  the  pneu- 
mono-hepatic  border,  will  make  the  liver  appear  small. 
An  actual  diminution  of  the  liver  can  be  diagnosed  only 
when,  with  decreased  Hat  area,  we  still  find  the  pneumono- 
bepatic  border  at  normal  height,  ami  we  can  exclude' all 
conditions  which  produce  elevation  or  twisting  of  the 
organ.  Tin-  most  difficult  eases  to  decide  are  those  where 
a  loop  of  intestine  lies  between  the  liver  and  the,  chest 
wall.  Frerichs  says  that  this  condition  may  be  surmised 
when  one  <>!'  the  diameters  of  the  liver  is  unusually  small 
as  compared  with  the   remaining  diameters. 

An  enlargement    of   the   area  of  hepatic   flatness  occurs 

with  hypertrophy  of  the  organ  Itself;  also  with  any  re- 
traction of  the  lung  which  elevates  the  pneumono-hepatio 
border.     Displacements  of  the  liver  by  pressure  of  tho- 


44  PERCUSSION   OUTLINES. 

racic  tumors  or  pleuritic  exudations  cause  an  enlargement 
of  the  flat  area.  In  all  such  cases,  therefore,  it  is  ob- 
vious that  no  diagnosis  regarding  the  actual  size  of  the 
liver  can  be  made  until  all  associated  conditions  have  been 
carefully  reviewed. 

Weil  gives  the  following  valuable  schedule  of  possible 
complications,  which  cannot  fail  to  be  of  service  in  de- 
ciding many  obscure  cases. 

1.  The  inferior  border  of  the  liver  is  in  normal  posi- 
tion :  — 

(a)  The  pneumono-hepatic  border  is  high :  en- 
largement of  liver  upward  ;  medium-sized  pleu- 
ritic effusion ;  enlargement  of  liver  with  coin- 
cident dislocation  upward,  as  in  hyperemia  or 
amyloid  liver  with  ascites. 

(6)  The  pneumono-hepatic  border  is  low  :  emphy- 
sema of  moderate  degree.  In  such  a  case  the 
height  of  the  hepatic  dull  zone,  above  the 
pneumono-hepatic  line,  is  normal  or  increased. 

2.  The  inferior  border  of  the  liver  is  too  low. 

(a)  The  pneumono-hepatic  border  is  high :  very 
large  hypertrophy  or  tumor  of  liver :  large  pleu- 
ritic exudation. 

(6)  The  pneumono-hepatic  border  is  normal :  hy- 
pertrophy of  liver  ;  anomalous  position  of  the 
same. 

(c)  The  pneumono-hepatic  border  is  low  :  exces- 
sive emphysema  ;  pneumothorax. 

3.  The  inferior  border  of  the  liver  is  too  high. 

(a)  The  pneumono-hepatic  border  is  high  :  dislo- 
cation upward. 

(6)  The  pneumono-hepatic  border  is  normal :  atro- 
phy of  liver ;  dislocation  upward. 


LIVER  45 

4.  The  hepatic  flatness  is  entirely  absent. 

Oblique  position  of  the  liver,  with  ineteorismus  and 
ascites ;  intervention  of  intestines  ;  formation 
of  free  gas  in  the  peritoneal  cavity. 

5.  Transposition  of  the  hepatic  flatness  to  the  opposite 
side  of  the  body  in  cases  of  congenital  transposition  of  all 
the  internal  viscera. 


CHAPTER  VI. 

THE   SPLEEN. 

Anatomy.  —  The  spleen  is  situated  in  the  left  hypo- 
chondrium,  between  the  diaphragm,  the  left  kidney,  and 
the  posterior  wall  of  the  stomach.  It  extends  from  the 
ninth  to  the  eleventh  rib,  with  its  longest  diameter  di- 
rected obliquely  forward  and  downward,  following  the 
course  of  these  ribs.  We  distinguish  an  upper  end 
(Plate  II.)  distant  two  centimeters  at  least  from  the 
body  of  the  tenth  dorsal  vertebra,  and  an  anterior  end, 
corresponding  to  the  point  lying  nearest  the  middle  line 
of  the  body.  When  the  spleen  is  oval  in  shape,  besides 
the  upper  and  anterior  ends,  we  may  speak  of  two  bor- 
ders, an  anterior  and  a  posterior,  which  unite  at  G  and 
H.  The  anterior  end  is  about  in  the  axillary  line,  and 
does  not  extend  beyond  the  linea  costo-articularis  under 
normal  conditions.  The  anterior  edge  corresponds  to  the 
course  of  the  ninth  rib  ;  in  its  upper  portion  it  is  covered 
by  lung,  and  only  emerges  from  the  pulmonary  edge  in 
the  posterior  axillary  line.  In  the  angle  made  by  the 
lower  border  of  the  lung  and  the  spleen,  the  stomach  and 
colon  are  located.  The  posterior  edge  follows  the  elev- 
enth rib,  and  overlaps  the  left  kidney  a  short  distance 
in  its  middle  third.  Where  the  posterior  edge  of  the 
spleen  and  the  outer  border  of  the  kidney  meet,  the  de- 
scending colon  is  situated.  When  the  shape  of  the  spleen 
is  more  rhomboidal,  its  front  edge  follows  the  course  of 
the  ninth  rib  still  farther  forward  than  in  the  oval  form, 


SPLEEN.  47 

and  the  lower  edge  runs  obliquely  backward  and  down- 
ward. 

Notice  :  1.  About  a  third  of  the  spleen  (the  upper 
end,  a  part  of  the  front  and  posterior  borders)  is  covered 
by  lung. 

2.  The  posterior  border  of  the  spleen  lies  in  apposition 
to  the  anterior  border  of  the  left  kidney  for  about  a  third 
of  its  course. 

PERCUSSION. 

We  are  unable  to  define  by  percussion  that  portion  of 
the  spleen  which  is  covered  by  lung.  We  can  at  most 
obtain,  in  some  cases,  by  strong  percussion,  a  relatively 
dull  sound  above  the  lower  edge  of  the  lung,  extending 
from  the  anterior  axillary  line  to  midway  between  the 
posterior  axillary  and  scapular  lines,  or  to  the  scapular 
line.  The  upper  border  of  this  ai'ea  is  parallel  to  the 
pneumono-splenic  border  at  a  distance  of  two  or  three 
centimeters.  Between  the  scapular  line  and  the  vertebras 
relative  dullness  for  the  spleen  is  no  more  demonstrable 
than  is  the  case  with  the  liver  on  the  other  side.  Be- 
tween the  anterior  axillary  line  and  the  mammillary  line, 
as  a  rule,  there  is  also  no  relative  dullness  above  the  edge 
of  the  left  lung.  On  gentle  percussion  the  sound  here  is 
as  loud  as  it  is  higher  up,  and  on  stronger  percussion  it 
usually  becomes  tympanitic,  because  the  stomach,  which 
is  full  of  air,  is  set  in  vibration  underneath  the  lung. 
The  same  condition  frequently  occurs  also  between  the 
posterior  axillary  and  scapular  lines,  so  that  here  like- 
wise there  is  no  relative  dullness  above  the  pneumono- 
splenic  boundary. 


48  PERCUSSION   OUTLINES. 

DETERMINATION    OF    THE    BOUNDARIES    OF    THE 
SPLEEN. 

The  best  position  for  the  patient  to  assume  is  decubi- 
tus on  the  right  side,  diagonal  decubitus  (on  the  right 
shoulder-blade  and  right  hip),  or  standing  erect.  The 
disadvautage  of  the  first  position  is  that  the  lower  end 
of  the  organ  is  often  difficult  to  define,  from  the  near 
approach  of  the  crest  of  the  ileum  to  the  lower  ribs. 
The  disadvantage  of  the  second  position  is  that  unless 
the  patient  is  near  the  edge  of  the  bed,  it  is  often  im- 
possible to  define  the  posterior  boundary.  While  the 
chief  disadvantage  of  the  last  position  is  the  impossi- 
bility at  times  of  placing  the  patient  erect.  Where 
great  accuracy  is  sought,  it  is  well  to  compare  the  bound- 
aries found  in  the  recumbent  position  with  those  obtained 
while  the  patient  is  upright.  If  the  spleen  is  percussed 
in  the  upright  position,  we  must  in  the  first  place  deter- 
mine the  pneumono-splenic  border,  by  percussing  verti- 
cally downward  from  above,  in  the  vertebral,  scapular, 
posterior,  middle,  and  anterior  axillary  lines.  We  thus 
obtain  the  border  B  D  (Plate  V.),  corresponding  to  the 
lower  edge  of  the  left  lung.  Below  the  edge  of  the  lung 
we  find,  as  far  as  the  point  E  in  the  posterior  (or  middle) 
axillary  line,  a  dull  sound ;  further  forward,  a  tympanitic 
sound.  If  we  percuss  vertically  downward  in  the  axillary 
region,  we  find,  at  I  and  K,  the  transition  of  the  dull  to 
the  loud  tympanitic  sound,  and  thus  obtain  the  oval  fig- 
ure of  dullness  E  K  L.  Posteriorly,  the  splenic  dullness 
becomes  merged  in  that  of  the  kidney  and  thick  dorsal 
muscles,  and  is  difficult  to  outline. 

The  size  of  the  organ  is  determined  by  the  vertical 
diameter  of  dullness  in  the  axillary  line,  and  by  the  dis- 
tance of  the  anterior  end  of  dullness  from  the  costal  arch. 
To  give  the  normal  boundaries  of  splenic  dullness  in  the 


SPLEEN.  49 

upright  position  more  exactly,  the  pneumono-splenic 
angle,  as  a  rule,  is  in  the  posterior  axillary  line;  or  be- 
tween it  and  the  middle  axillary  line,  at  the  level  of  the 
ninth  rib  ;  more  rarely  of  the  ninth  or  eighth  intercostal 
space.  The  distance  of  the  lower  splenic  border  from  the 
upper  one  in  the  vertical  line  is  five  and  a  half  to  six  and 
a  half,  sometimes  even  seven,  centimeters.  The  anterior 
end  of  the  spleen  is  behind  the  costo-articular  line,  or 
at  most,  just  reaches  it ;  or  in  other  words  is  four  to  six 
centimeters  from  the  costal  arch.  In  using  the  linea 
costo-articular  is  as  a  defining  point  for  the  position  of  the 
anterior  border  of  the  spleen,  we  must  remember  that,  on 
account  of  the  varying  length  of  the  eleventh  rib  in  dif- 
ferent people,  this  line  may  be  carried  more  toward  the 
front,  sometimes  more  towards  the  back. 

To  define  the  splenic  dullness  we  must  employ  some- 
times gentle,  sometimes  strong  percussion.  Thus,  while 
the  pneumono-splenic  boundary  between  the  axillary  and 
scapular  lines,  as  a  rule,  is  better  obtained  by  medium 
strong  percussion,  the  definition  from  the  tympanitic 
sound  of  the  stomach  and  colon,  in  cases  where  these  or- 
gans contain  much  gas,  is  better  made  by  gentle  percus- 
sion, since  by  strong  percussion  the  organs  lying  behind 
the  spleen  are  set  in  vibration,  and  their  tympanitic 
sound  either  causes  the  splenic  dullness  to  appear  too 
small,  or  to  disappear  altogether.  On  the  other  hand, 
the  difference  in  sound  is  more  distinct  on  strong  per- 
cussion when  the  stomach  and  colon  have  fluid  or  solid 
contents.  The  sound  is  seldom  perfectly  fiat  in  the  re- 
gion where  the  spleen  is  accessible  to  percussion.  There 
is  usually  a  tympanitic  accessory  sound  which  La  espe- 
cially distinct  toward  the  edges  of  the  organ.  The  boun- 
daries of  the  spleen,  therefore,  as  of  the  liver,  are  to  be 
placed  where  the  tympanitic  sound  becomes  clear  and 
loud  ;  or  better,  where  the  loud  tympanitic  sound  of  the 
i 


50  PERCUSSION   OUTLINES. 

stomach  and  colon  begins  to  be  dulled,  as  we  approach  the 
splenic  region. 

On  change  from  the  upright  to  the  right  lateral  decu- 
bitus, the  pneumono-splenic  border  sinks  two  to  four  cen- 
timeters, and  the  anterior  extremity  of  the  spleen  ad- 
vances to  or  beyond  the  linea  costo-articularis.  The  dull 
area  of  the  spleen  thus  assumes  a  narrower  and  more 
horizontal  position. 

Slight  deviations  from  the  conditions  already  given  are 
exceedingly  common  ;  as,  for  instance,  instead  of  the  oval 
figure  described  above  as  normal,  we  may  obtain  by  our 
percussion  a  figure  distinctly  triangular  or  rhomboidal  ; 
or,  especially  when  the  patient  is  in  the  upright  posture, 
the  longest  diameter  may  run  more  vertically.  Still 
these  are  all  rather  exceptions  to  the  rule.  Other  varia- 
tions from  the  conditions  mentioned  are  caused  by  differ- 
ences of  age  in  the  individual.  Corresponding  to  the 
lower  position  of  the  pneumono-splenic  border,  we  always 
find  in  advanced  age  the  upper  border  of  the  splenic  dull- 
ness deeper,  and  the  splenic  dullness  itself  smaller  than 
in  persons  of  middle  age.  It  is  of  the  greatest  practical 
importance  to  know  all  the  conditions  which  render  de- 
termination of  the  splenic  boundaries  either  difficult  or 
impossible.  Cases  are  by  no  means  rare  in  which,  while 
the  lower  border  of  the  left  lung  has  a  normal  position, 
yet  the  splenic  dullness  cannot  be  demonstrated  at  all, 
or  it  has  a  very  circumscribed  area.  In  such  cases  the 
pulmonic  sound  suddenly  changes  to  a  loud  tympanitic 
one.  The  conditions  which  cause  a  diminution  or  disap- 
pearance of  the  splenic  dullness  in  perfectly  healthy  indi- 
viduals are  usually  merely  transitory,  and  depend  on  the 
presence  of  a  considerable  volume  of  gas  in  the  organs  sur- 
rounding the  anterior  and  posterior  edges  of  the  spleen, 
that  is,  in  the  stomach  and  colon.  They  are  of  less  prac- 
tical  importance  than  a  diffused  dullness  so  frequently 


SPLEEN.  51 

seen  in  health,  extending  far  beyond  the  normal  bounda- 
ries, and  they  do  not  lead  so  often  to  a  false  diagnosis. 
This  diffused  dullness  in  the  region  of  the  spleen  is 
readily  explained.  If  the  underlying  colon  and  stomach 
do  not  contain  gas,  but  are  filled  with  solid  or  liquid 
substances,  they  give  forth  a  sound  which  is  indistin- 
guishable from  that  of  the  spleen.  The  splenic  dullness 
then  runs  over  into  that  of  these  organs,  and  therefore 
appears  enlarged.  In  such  cases,  an  examination  after 
fasting  for  a  time,  or  after  a  brisk  cathartic,  will  show 
that  the  splenic  dullness  may  be  normal  after  all.  Again, 
a  very  fat  omentum  may  stretch  to  the  left  end  of  the 
transverse  colon,  and  displace  it  from  the  thoracic  wall. 
The  shape  of  the  dullness  will  often  rouse  suspicion  that 
we  have  something  else  before  us;  as,  for  example,  when 
the  dullness  is  only  five  or  six  centimeters  broad  and 
reaches  to  the  costal  arch,  or  when  it  has  a  breadth  of 
eleven  centimeters  and  does  not  extend  beyond  the  linea 
costo-articularis.  In  cases  where  the  shape  of  the  dull- 
ness is  correct  for  that  of  the  spleen,  but  differs  only 
in  point  of  size,  we  may  often  arrive  at  the  truth  by 
comparative  percussion  in  different  positions.  The  true 
splenic  tumor  gives  approximately  the  same  relation  to 
the  linea  costo-articularis  on  repeated  percussion,  while 
the  boundaries  of  the  apparent  tumor  are  characterized 
by  their  changeableness. 

Passive  Mobility.  —  The  displacements  to  which  the 
splenic  dullness  is  subject  on  change  of  position  have 
been  already  mentioned.  There  still  remain  the  respira- 
tory displacements,  which  are  worthy  of  brief  notice. 
They  have  been  hinted  at  above  in  speaking  of  the  po- 
sition of  the  diaphragm.  With  every  inspiration  the 
splenic  dullness  is  diminished  in  size  and  brought  lower, 
while  the  anterior  end  of  the  organ  sometimes  remains 
undisturbed  in    its  place   and   sometimes  moves  forward 


52  PERCUSSION   OUTLINES. 

and  downward  one  or  two  centimeters.  The  descent  of 
the  lower  border  depends  on  the  descent  of  the  whole 
organ  through  contraction  of  the  diaphragm  ;  the  lower 
border,  after  the  deepest  possible  inspiration,  is  about  one 
centimeter  lower,  and  the  pneumono-splenic  border  about 
three  to  four  centimeters  lower  than  before.  If  a  deep 
inspiration  is  made  while  in  the  right  lateral  decubitus, 
the  splenic  dullness  disappears  completely,  except  in  a 
narrow  line.  In  deep  expiration  the  splenic  dullness  as- 
cends and  enlarges,  because  the  lower  border  makes  a 
smaller  excursion  than  the  upper  border. 

PATHOLOGY. 

The  spleen  may  be  either  diminished  or  increased  in 
size,  or  it  may  be  dislocated. 

In  mentioning  the  difficulties  attending  the  determina- 
tion of  the  splenic  boundary,  we  called  attention  to  the 
fact  that  sometimes  the  splenic  dullness  was  wholly  ab- 
sent. In  certain  diseases,  emphysema,  gas  or  fluid  in  the 
peritoneal  sac,  we  find  it  either  much  diminished  or  ab- 
sent, for  reasons  sufficiently  obvious.  In  wandering  spleen 
absence  of  dullness  in  the  normal  area  may  assume  diag- 
nostic importance,  especially  when  a  tumor  situated  else- 
where in  the  abdomen  can  be  replaced,  and  supply  the 
absent  dullness. 

Splenic  Tumor. —  The  cautions  mentioned  above  will 
fully  illustrate  the  care  necessary  in  determining  the  ex- 
istence of  splenic  enlargement.  A  diagnosis  of  such  en- 
largement, therefore,  should  not  be  made  from  one  ex- 
amination. Moderate  enlargements  of  the  organ  are 
shown  by  increase  of  the  vertical  diameter  of  the  dull- 
ness from  five  or  six  to  nine  or  twelve  centimeters ;  also 
by  the  advance  of  the  anterior  end  to,  or  beyond,  the 
costal  arch.  At  the  same  time  the  pneumono-splenic 
border  moves  upward.     The  increase  in  the  breadth  of 


SPLEEN.  53 

the  dullness  is  caused  by  the  descent  of  the  lower  and  the 
ascent  of  the  upper  border  of  the  spleen.  The  lower 
border  may  then  reach  in  the  right  lateral  decubitus  as 
far  as  the  twelfth  rib  or  even  lower,  the  pneumono-splenic 
border  may  stand  in  the  middle  axillary  line  at  the 
eighth  rib,  seventh  intercostal  space,  or  at  the  seventh 
rib  even. 

The  intensity  of  dullness  in  enlarged  spleen  is  almost 
without  exception  greater  than  that  in  the  normal 
spleen. 

The  dislocation  resulting  from  fluid  in  the  chest  is  for- 
ward and  downward,  or  the  spleen  may  be  made  to  as- 
sume a  more  vertical  position,  and  at  the  same  time  be 
depressed. 


CHAPTER  VII. 

THE   STOMACH. 

Anatomy.  —  The  stomach  is  so  placed  in  the  abdomen 
that,  no  matter  what  changes  of  volume  it  undergoes, 
about  three  quarters  of  it  lie  in  the  left  hypochondrium 
and  one  quarter  in  the  epigastrium.  Its  longest  diameter 
runs  obliquely  from  behind  downward  and  forward  to- 
ward the  right  side  ;  the  pyloric  end  curves  slightly  up- 
ward, as  a  rule,  in  the  median  line,  so  that,  on  moderate 
distention  of  the  stomach  the  lowest  point  of  the  organ 
falls  in  the  middle  of  the  space  between  the  end  of  the 
processus  xiphoideus  and  the  umbilicus.  A  horizontal 
line  from  this  point  to  the  left  border  of  the  ribs  runs 
just  below  the  junction  of  the  greater  curvature  with  the 
costal  arch. 

The  beginning  of  the  stomach,  the  cardiac  portion 
(Plate  I.),  or,  more  correctly,  the  abdominal  portion  of 
the  oesophagus,  is  about  on  the  level  of  the  sternal  edge 
of  the  left  sixth  intercostal  space,  distant  at  least  ten 
centimeters  from  the  anterior  wall  of  the  thorax. 

The  pyloric  portion  lies  in  the  right  half  of  the  epigas- 
trium, and,  as  a  rule,  barely  reaches  to  the  right  costal 
arch. 

The  small  curvature  hugs  the  lumbar  vertebrae. 

The  great  curvature  is  turned  toward  the  lateral  wall 
of  the  left  hypochondrium  and  the  inner  side  of  the  an 
terior  abdominal  wall. 

The  front,  upper  side,  of  the  stomach,  while  in  the  left 


STOMACH.  55 

hypochondrium,  follows  the  concavity  of  the  diaphragm, 
the  fundus  occupying  the  highest  point  of  the  latter 
(level  of  the  fifth  rib).  This  surface  of  the  stomach  is, 
to  a  great  extent,  overlaid  by  the  base  of  the  left  lung  ; 
while  the  portion  located  in  the  epigastrium  is  in  part 
separated  from  the  anterior  abdominal  wall  by  the  left 
lobe  of  the  liver. 

The  lower  posterior  surface  of  the  stomach,  which  is  in 
part  directed  toward  the  dorsal  wall  of  the  abdomen,  and 
in  part  directed  downward,  at  no  place  comes  in  direct 
contact  with  the  abdominal  wall.  Along  the  greater  curv- 
ature runs  the  transverse  colon,  ending  in  the  region  of 
the  fundus  as  the  flexura  coli  sinistra. 

Notice:  1.  The  whole  posterior  and  lower  side  of  the 
stomach  nowhere  lies  next  the  wall  of  the  body. 

2.  The  cardia,  small  curvature,  a  part  of  the  front  up- 
per surface,  are  separated  from  the  anterior  abdominal 
wall  by  the  left  lobe  of  the  liver  ;  another  part  of  the 
front  upper  side  and  the  great  curvature  are  separated 
from  the  wall  of  the  thorax  by  lung. 

3.  Only  a  small  portion  of  the  anterior  superior  sur- 
face lies  directly  against  the  abdominal  wall.      (Plate 

I.,  W.) 

PERCUSSION. 

Percussion  of  the  stomach  presents  certain  difficulties 
due  to  its  varying  size,  according  to  the  degree  of  dis- 
tention with  fluid,  solid,  and  gas,  and  to  the  tension  of  the 
abdominal  wall.  The  sound  given  forth  is,  according  to 
these  different  conditions,  dull,  tympanitic,  or  metallic. 
In  addition,  there  is  also  the  sound  of  the  colon,  which  we 
must  distinguish  from  that  of  the  stomach,  and  which, 
with  the  changeable  degree  of  distention,  is  often  diffi- 
cult. 

In  percussing  the  stomach,  we  assume  the  organ  to  be 
partly  filled.     In  the  dorsal  decubitus  the  solid  and  fluid 


56  PERCUSSION   OUTLINES. 

contents  collect  in  the  posterior  portion  of  the  stomach. 
While  the  gaseous  contents  rise  anteriorly,  and  with  a 
moderate  degree  of  distention  of  the  gastric  wall,  occa- 
sion a  tympanitic  sound.  The  boundaries  of  this  sound 
are  as  follows,  under  the  conditions  given  above. 

1.  Above  and  to  the  right  the  gastro-hepatic  boundary. 
(Plate  I.) 

2.  Above  and  to  the  left  the  pneumono-gastric  bound- 
ary. 

3.  Below  the  lower  boundary  of  the  stomach,  corre- 
sponding to  the  greater  curvature. 

4.  Between  the  gastro-hepatic  and  pneumono-gastric 
boundaries,  in  cases  where  the  left  lobe  of  the  liver  is 
overlaid  toward  the  left  by  the  absolute  cardiac  flatness, 
is  a  gastro-cardiac  boundary. 

Of  these  boundaries  the  only  actual  one  is  the  lower. 
This  is  determined  by  a  change  from  the  tympanitic 
sound  of  the  stomach  to  one  of  a  different  pitch  or  clear- 
ness, coming  from  the  transverse  colon  ;  and  it  is  situated 
midwav  between  the  end  of  the  processus  xiphoideus  and 
the  umbilicus,  and  runs  thence  in  a  tolerably  horizontal 
line  to  the  left  hypochondrium,  and  crosses  the  costal 
arch  about  on  a  level  with  the  ninth  costal  cartilage  ; 
thence  following  very  nearly  the  course  of  the  eighth  rib, 
it  disappears  behind  the  lower  edge  of  the  lung  in  the 
middle  axillary  line.  The  lower  border  of  the  stomach 
can  be  followed  but  a  few  centimeters  to  the  right  of  the 
median  line,  because  it  passes  behind  the  lower  edge  of 
the  liver.  The  lower  border  varies  from  the  above  points 
according  to  the  greater  or  less  degree  of  distention  of 
the  stomach.  The  middle  and  right  hand  portions  of 
this  boundary  vary  but  little  from  the  points  given  ;  the 
left,  on  the  other  hand,  is  capable  of  considerable  varia- 
tion. The  less  the  degree  of  distention  of  the  organ,  the 
more  does  it  retract  from  the  pneumono-splenic  angle,  till 


STOMACH.  57 

it  may  meet  the  lung  at  the  sixth  rib  even.  In  great 
distention  of  the  stomach,  on  the  other  hand,  this  entire 
angle  may  be  filled  out.  From  the  above  facts,  it  is  plain 
that  we  must  be  content  with  defining  that  portion  of  the 
stomach  lying  next  the  anterior  thoracic  and  abdominal 
wall. ' 

PATHOLOGY. 

Diminution  of  the  gastric  area  of  resonance  may  occur 
from  enlargement  of  the  left  lobe  of  the  liver,  from  sple- 
nic tumor,  from  an  enlarged  heart,  or  from  emphysema  of 
the  lung;  the  stomach  in  each  instance  remaining  of 
normal  size,  but  being  overlaid  by  the  pathological 
organs. 

Increase  of  the  gastric  area  of  resonance,  gastric  dila- 
tation is  of  greater  importance.  When  the  patient  is 
examined  while  lying  on  the  back,  the  lower  border  cor- 
responding to  the  greater  curvature,  is  found  to  be  lower 
than  normal,  either  at  the  umbilicus,  below  it,  or,  in  ex- 
treme cases,  near  the  symphysis  pubis.  When  the  patient 
is  examined  in  the  erect  position,  a  dullness  is  obtained, 
the  lower  border  of  which  is  somewhat  lower  than  that 
of  the  tympanitic  resonance  found  in  the  horizontal  po- 
sition, and  is  due  to  the  gravitation  of  the  contents  of 
the  stomach. 


CHAPTER   VIII. 

THE   KIDNEYS. 

Anatomy.  —  The  kidneys  lie  on  each  side  of  the  verte- 

Dral  column,  close  to  the  posterior  abdominal  wall,  at  the 

level   of  the  last  dorsal  and  two  or  three  upper  lumbar 

vertebrae.     The  right  kidney  is  usually  a  little  lower  than 

the  left  (Plate  III.)     The  concave  edge  is  toward  the 

spine,  the  convex  edge  is  directed  outward.     The  upper 

end  of  the  right  kidney  extends  under  the  liver,  so  that 

about  a  third  of  it  is  covered  by  the  latter.     The  left 

kidney  touches  the  posterior  lower  border  of  the  spleen, 

as  described  above.     Viewed  from  behind,  the  kidneys 

are  overlaid  and  about  half  covered  by  the  eleventh  and 

twelfth  ribs.     The  duodenum  and  ascending  colon  are  in 

front  of  the  right   kidney,  and  the  descending  colon  is 

in  front   of    the   left  kidney.     The  colon  encircles  the 

outer  edge  of  each  kidney.     Behind,  the  kidneys  lie  on 

a  thick  layer  of   muscle,  the  pillars  of    the  diaphragm, 

quadratus  lumborum,  transversus  abdominis,  sacro-spina- 

lis,  and  latissimus  dorsi.     The  lower  end  of  the  kidneys 

is  two  to  six  centimeters  above  the  crest  of  the  ileum. 

The  outer  edge  extends  ten  centimeters  from  the  median 

line,  so  that  the  two  outer  edges  are  twenty  centimeters 

apart. 

PERCUSSION. 

*In  the  normal  condition,  the  kidneys  are  not  acces- 
sible to  percussion,  owing  to  the  thickness  of  the  muscles 
of   the  back,  and    to  the  resonance  of  the  neighboring 


THE  KIDNEYS.  59 

intestines.  The  dullness  obtained  in  the  renal  region, 
and  usually  attributed  to  the  kidneys  (Plate  VII.,  H  I 
and  K  l),  has  been  found  by  Weil  to  be  the  same  after 
extirpation  of  one  kidney  ;  and  in  a  case  of  floating  kid- 
ney this  dullness  was  the  same  both  before  and  after 
reposition  of  the  organ. 

Extreme  cases  of  hydronephrosis  and  very  large  tumors 
of  the  kidneys  may  produce  a  distinct  flat  area  of  their 
own, 


CHAPTER  IX. 

THE  BLADDEE. 

Anatomy.  —  The  bladder  is  situated  in  the  pelvis,  be- 
hind the  pubes.  In  the  male,  the  rectum  is  directly 
behind  it ;  and  in  the  female,  the  uterus  and  vagina. 
The  shape  and  position  of  the  bladder  are  greatly  in- 
fluenced by  age,  sex,  and  the  degree  of  distention  of  the 
organ.  In  infancy,  the  bladder  is  conical  and  projects 
into  the  abdomen  above  the  pubes.  In  the  adult,  when 
empty,  it  is  a  triangular  sac  (three  centimeters  in  diam- 
eter usually)  flattened  from  before  backward,  with  its 
apex  reaching  nearly  as  high  as  the  upper  border  of  the 
symphysis  pubis.  When  slightly  distended,  it  has  a 
rounded  form  ;  when  greatly  distended,  it  is  oval.  Its 
longest  diameter  in  the  latter  condition  is  vertical  and 
curved  slightly  forward.  In  the  female,  the  bladder  is 
larger  in  the  transverse  than  in  the  vertical  diameter,  and 
is  said  to  be  more  capacious  than  in  the  male.  When 
contracted,  it  has  two  lateral  sinuses,  which  override 
the  vagina  like  saddle-bags.  This  fact,  together  with  the 
greater  roominess  of  the  female  pelvis,  permits  a  consid- 
erable accumulation  of  urine  in  the  bladder  without  any 
appearance  of  the  organ  above  the  pubes. 

The  average  capacity  of  the  bladder,  in  health,  is  500 
cubic  centimeters. 

PERCUSSION. 

The  empty  bladder  in  the  adult  cannot  be  reached  by 
percussion.     How  large  a  quantity  of  urine  is  requisite  to 


THE  BLADDER.  61 

render  the  bladder  accessible  depends  on  the  curve  and 
and  thickness  of  the  abdominal  wall,  and  on  the  condition 
of  the  neighboring  intestine.  The  first  effect  of  the  col- 
lection  of  urine  within  the  bladder  is  to  render  the  organ 
spherical ;  and  it  is  not  till  a  considerable  quantity  is 
present,  even  in  the  most  favorable  subjects,  that  any- 
thing like  certainty  can  be  attained  on  percussion.  We 
have  found  that  an  area  of  flatness  extending  ten  centi- 
meters above  the  pubes  and  nine  centimeters  in  breadth, 
coincided  with  six  hundred  and  seventy  cubic  centimeters 
of  urine  drawn  immediately  after  the  measurements  were 
made,  in  a  man  with  emaciated  and  relaxed  abdominal 
wall.  In  another  man,  with  a  moderately  prominent  ab- 
domen, four  hundred  cubic  centimeters  did  not  give  any 
evidence  of  its  presence. 


CHAPTER  X. 


THE  UTERUS. 


In  the  unimpregnated  condition,  the  uterus  lies  below 
the  brim  of  the  pelvis.  During  pregnancy,  after  the 
fourth  month  it  begins  to  rise  above  the  brim,  and  may 
be  outlined  under  favorable  conditions.  At  the  fifth 
month,  it  stands  half  way  between  the  symphysis  pubis 
and  the  umbilicus,  in  the  median  line.  At  the  sixth 
month  it  has  reached  the  umbilicus.  At  the  seventh 
month  it  extends  one  third  the  distance  between  the 
umbilicus  and  the  processus  xiphoideus.  At  the  eighth 
month,  it  is  two  thirds  the  distance  between  the  above 
points  ;  and  at  the  ninth,  it  touches  the  lower  end  of  the 
processus  xiphoideus. 


Fig.  4.    (Chadwick.) 


LUNAR 

MONTHS. 

9th. 


THE   UTERUS.  63 

The  resonance  of  the  surrounding  intestines  often  ob- 
scures the  percussion  outlines  of  the  impregnated  uterus, 
and  more  information  can  usually  be  obtained  by  palpation 
than  by  percussion. 


CHAPTER  XL 

THE  PERITONEUM. 

Ascites.  —  The  amount  of  fluid  within  the  peritoneum 
must  be  considerable  to  give  evidence  of  its  presence  by 
percussion.  If  it  lies  next  the  abdominal  wall  we  obtain 
dullness  or  flatness,  according  to  its  quantity.  Free  fluid 
gravitates  to  the  lowest  part  of  the  sac,  so  that  the 
boundaries  of  dullness  or  flatness  vary  with  the  position 
of  the  patient.  With  moderate  effusions,  the  lower  bor- 
der of  the  lungs,  heart,  and  liver  stand  higher  than  normal. 
The  hepatic  flatness  appears  to  be  decreased  in  size,  be- 
cause the  intestines  are  displaced  upward,  and,  where  the 
collection  of  fluid  is  large,  the  liver  is  tilted  on  its  axis.  The 
splenic  dullness  is  also  found  to  be  higher  than  normal  and 
smaller,  unless  the  ascites  depends  on  a  condition  which 
gives  rise  to  splenic  tumor.  When  the  patient  is  in  the 
supine  position  the  upper  border  of  flatness  is  crescent- 
shaped,  with  the  concavity  directed  upward.  In  the  erect 
posture  it  is  horizontal.  In  the  lateral  decubitus  the 
flatness  changes  to  the  lower  side,  and  is  replaced  in  the 
opposite  flank  by  the  clear  resonance  of  the  intestines. 
When  the  amount  of  fluid  is  very  great  a  flat  sound  is 
obtained  everywhere,  except  in  the  epigastrium,  near  the 
processus  xiphoideus,  where  it  remains  somewhat  tym- 
panitic. 

The  points  of  differentiation  from  Ovarian  Tumor  are 
as  follows  :  — 

In  Ascites,  in  the  dorsal  decubitus,  the  sound  is  tym- 


THE   PERITONEUM.  65 

panitic,  in  a  curved  line  with  the  concavity  upward,  the 
epigastrium  being  resonant  and  the  flanks  flat.  Fur- 
thermore, change  of  position  gives  modification  of  the 
curve. 

In  Ovarian  Tumor,  the  tympanitic  resonance  remains 
longest  in  the  flanks ;  while,  as  a  rule,  the  highest  point 
of  flatness  is  in  the  middle  line  of  the  body,  and  change 
of  position,  unless  the  tumor  be  small,  gives  rise  to  less 
modification  of  the  flatness.  (Olshausex.) 

The  above  distinctions  are  not  absolute,  since  strong 
percussion  may  bring  out  a  deep-seated  resonance  in  colon 
or  ccecum,  or  deep  pressure  may  displace  ascitic  fluid. 

In  a  patient  with  considerable  ascites,  we  found  that 
in  the  dorsal  decubitus,  the  line  of  flatness  commenced  at 
the  costal  arch  in  the  parasternal  line  on  each  side,  and 
swept  round  in  a  gentle  curve  to  two  and  a  half  centime- 
ters below  the  umbilicus. 

GAS  IN  THE   PERITONEUM. 

If  there  is  free  gas  in  the  peritoneum  the  sound  has  the 
same  pitch  and  distinctness  throughout  the  whole  abdo- 
men ;  this  is,  according  to  the  degree  of  distention  of  the 
abdomen,  tympanitic,  or  metallic. 

The  hepatic  flatness  and  splenic  dullness  may  be  absent 
when  the  amount  of  gas  is  large,  and  there  are  no  adhe- 
sions of  these  organs  to  the  abdominal  wall. 

In  Meteorism  similar  results  to  the  above  may  be  ob- 
tained by  percussion,  but  usually  the  diffevenl  clearness 
and  pitch  of  the  sound  in  various  parts  of  the  abdomen 
indicate  that  the  gas  is  contained  in  coils  of  intestine  of 
different  si/.e,  and  not  in  a  single  cavity.  More  impor- 
tant data  for  distinguishing  between  these  two  condi- 
tions, however,  are  obtained  by  other  methods  of  inves- 
tigation. 

5 


Plate  I. 


Anatomical  Borders  —  Anterior  View.     (Weil.) 


A  B,  border  of  the  right  pleural  nc. 

C  0,  border  of  the  left  pleural  sac. 

E  P,  edge  of  the  right  lung. 

G  H,  edge  of  the  left  lung. 

I,  upper  incinura  Interlobular!*  of  the  right  lung. 

K.  lower  inclsura  interlobular™  of  the  right  lung. 

L,  left  incigura  interlobular™. 

M  N,  right  border  of  the  heart. 

N  O,  lower  border  of  the  heart. 

P  O,  left  border  of  the  heart. 


Q,  sinus TnediaatinocostallH,  situated  between  the  edge 
of  the  pleura  and  incisure  cardiaca  of  the  anterior 
border  of  the  left  lung. 

R,  highest  point  of  the  portion  of  liver  coTered  h\  1  uim 

S,  lnwrr  edge  of  the  llTer. 

T,  cardiac  portion  of  the  stomach. 

U.  pyloric  portion  of  the  stomach. 

V,  -mall  curvature  of  the  stomach. 

W,  greater  curvature  of  the  stomach. 


Plate  II. 


Anatomical  Borders  on  Left  Side.     (Weil.) 


A  8    lower  border  of  the  left  long. 
A  C,  lower  boundary  of  the  pleura. 
D  E,  tneisura  Interlobnlaris. 
F,  edge  of  the  left  lobe  of  the  Iirer. 


H  G,  anterior  and  posterior  ends  of  the  spleen. 

K,  kidney. 

N,  stomach  in  moderate  distention. 


Plate  III. 


x.*r 


Anatomical  Borders  —  Posterior  View.     (Weil.) 

A,  B,  lower  border*  of  the  lung*.  H,  splevn. 

C,  0,  lower  borders  of  the  pleurtc.  I,  lower  border  of  the  ll»er. 

E,  F,  inrisiirn-  interlobulares.  K,  L,  kidney*. 

G,  point  where  th«  right  inclsura  divides  into  the  sulc.  interlob.  dcxt.  super,  ami  infer 


Plate  IV. 


Percussion  Borders  in  Middle  Age.     (Wkil.) 


ABCD,  area  of  cardiac  flatness. 
A  I  K.  area  of  cardiac  dullness. 
C  E,  lower  border  of  right  lung. 
D  F,  lower  border  of  left  lung. 


G,  H,  upper  borders  of  lungs. 

P  Q,  upper  border  of  hepatic  dullness 

L  M,  lower  border  of  hepatic  flatness. 

N  O,  lower  border  of  stomach  in  moderate  distention 


Plate  V. 


c^ 


Percussion  Borders  on  Left  Side.     (Weil.) 


A  B,  lower  border  of  hepatir  flatneM. 
C  D,  lower  border  of  left  lung. 


E  I  L,  splenic  duilnew. 
Q,  lower  border  of  stomach 


Plate  VI. 


■ 


-^K3--: 


\ 


% 


. 


Percussion  Borders  on  Right  Side.      (Weil.) 

A  B,  lower  border  of  the  right  lung.  C  0,  lower  border  of  hepatic  Mitt  lies* 

E  F,  upper  border  of  hepatic  dullness 


Plate  VII. 


Percussion  Borders  ou  the  Back.     (Wkil.) 

A  B,  upper  border  of  lungs  H  I,  K  L,  outer  borders  of  the  so-railed  renal  dullness. 

C  0,  lower  border  of  lungs.  M  N,  lower  borders  of  the  lungs  In  deepest  inspiration. 

E  H,  lower  border  of  spleen.  O  P,  shrinkage  of  upper  border  nf  lung  in  phthisis. 

K  F.  lower  border  of  hepatic  flatness. 


Plate  VIII. 


Percussion  Borders  in  Childhood.     (WlXL.) 


A  B  C  D,  cardiac  flatm-PH. 
I  G  H,  cardiac  dullness. 


EC,  FO,  lower  border*  of  the  lungs 
K,  lower  border  of  the  liver. 


Plate  IX. 


/.-— iflfc^ 


r> 


Percussion  Borders  in  Old  Age.     (Weil.) 

A  B  C  D,  cardiac  flatness.  C  E,  0  F,  lower  borders  of  the  lungs 

G  H,  cardiac  dullness.  M  L,  lower  border  of  hepatic  flatness. 

K,  upper  border  of  hepatic  dullness. 


